a nurse is admitting a client who has suspected appendicitis which of the following findings should the nurse report to the provider immediately a nurse is admitting a client who has suspected appendicitis which of the following findings should the nurse report to the provider immediately
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Nursing Elites

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

Correct answer: A

Rationale: A distended, board-like abdomen should be reported to the provider immediately because it indicates peritonitis, a serious complication of appendicitis resulting from a ruptured appendix. Option B, an elevated WBC count, may indicate infection but is not as urgent as a board-like abdomen. Option C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate immediate life-threatening complications. Option D, a slightly elevated temperature, is not as concerning as a distended, board-like abdomen.

2. What is the priority nursing action when preparing a neonate born with a gastroschisis defect for transport to a pediatric hospital for corrective surgery?

Correct answer: A

Rationale: The priority nursing action when preparing a neonate born with a gastroschisis defect for transport is to cover the exposed intestines with sterile moist gauze. This action helps prevent infection and keeps the tissue viable during transportation to the pediatric hospital for corrective surgery.

3. Which of the following vascular system changes result from aging?

Correct answer: D

Rationale: As individuals age, various changes occur in the vascular system. These changes include increased peripheral resistance of the blood vessels, decreased blood flow, and an increased workload of the left ventricle. Therefore, all the listed changes result from aging, making option D, 'All of the above,' the correct answer.

4. A client with Peptic Ulcer Disease who is taking Sucralfate PO has a new prescription for phenytoin to control seizures. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: Sucralfate can interfere with the absorption of phenytoin. To prevent this interaction, the client should allow a 2-hour interval between taking sucralfate and phenytoin. This interval helps ensure that each medication is absorbed effectively without affecting the other's absorption. Choices A, B, and D are incorrect because taking an antacid with sucralfate, taking sucralfate with a glass of milk, or chewing sucralfate thoroughly before swallowing are not necessary or recommended instructions to prevent the interaction between sucralfate and phenytoin.

5. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?

Correct answer: C

Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.

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