Difficulty: Medium
Average Score: 69%
Simulated
Passage / Scenario
The following scenario applies to the next 1 itemsThe nurse is caring for a client who presents with acute appendicitis
Item 1 of 1
History of Present Illness
19-year-old female admitted with abdominal pain localized to the right lower quadrant. The onset of pain was twelve hours ago, and the client now reports pain is worsening when the client coughs. Endorses nausea and has persistent vomiting.
Vital Signs
ÔÇó Oral temperature 101┬░ F (38.3┬░C)
ÔÇó Pulse 90/minute
ÔÇó Respirations 18/minute
ÔÇó Blood Pressure 110/66 mm Hg
ÔÇó Oxygen saturation 96% on room air
Laboratory Results
ÔÇó White blood cell count, 11,500 mm3 (5,000-10,000 mm3)
ÔÇó Creatinine, 0.9 mg/dL (0.6-1.2 mg/dL)
ÔÇó BUN 26 mg/dL (10-20 mg/dL)
ÔÇó Potassium 3.3 mEq/L (3.5-5 mEq/L)
Select two (2) findings from the clinical data that require immediate follow-up
Correct answer
A,D
Rationale
Fever (A) and nausea/vomiting (D) in appendicitis suggest ongoing inflammation or complications, requiring immediate follow-up to prevent rupture or peritonitis.