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Appendicitis NCLEX, Postoperative Care, NCLEX pre op/post op Exam Questions with Correct Answers
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Appendicitis NCLEX, Postoperative Care, NCLEX pre op/post op Exam Questions with Correct Answers
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Appendicitis NCLEX, PostoperativeCare, NCLEX pre op/post op Exam
Questions with Correct Answers
The nurse would increase the comfort of the patient with appendicitis by:
"a. Having the patient lie prone
b. Flexing the patient's right knee
c. Sitting the patient upright in a chair
d. Turning the patient onto his or her left side - Answer-Correct answer: B"
The patient with appendicitis usually prefers to lie still, often with the right leg flexed to
decrease pain.
"The nurse is caring for a patient in the emergency department with complaints of acute
abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower
abdominal quadrant, the patient complains of pain in the right lower quadrant. The
nurse will document this as which of the following diagnostic signs of appendicitis?
"a. Rovsing sign
b. referred pain
c. Chvostek's sign
d. rebound tenderness
correct answer: A" - Answer-Answer A
In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the
left lower quadrant, causing pain to be felt in the right lower quadrant.
Which of the following position should the client with appendicitis assume to relieve pain
?
A. Prone B. Sitting C. Supine D. Lying with legs drawn up - Answer-Correct Answer: D
Lying still with legs drawn up towards chest helps relive tension on the abdominal
muscle, which helps to reduce the amount of discomfort felt. Lying flat or sitting may
increase the amount of pain experienced
"When evaluating a male client for complications of acute pancreatitis, the nurse would
observe for:
"a. increased intracranial pressure.
b. decreased urine output.
c. bradycardia.
d. hypertension." - Answer-Correct Answer: B
Rationale: Acute pancreatitis can cause decreased urine output, which results from the
renal failure that sometimes accompanies this condition. Intracranial pressure neither
increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia,
usually is associated with pulmonary or hypovolemic complications of pancreatitis.
Hypotension can be caused by a hypovolemic complication, but hypertension usually
isn't related to acute pancreatitis."
,"When preparing a male client, age 51, for surgery to treat appendicitis, the nurse
formulates a nursing diagnosis of Risk for infection related to inflammation, perforation,
and surgery. What is the rationale for choosing this nursing diagnosis?
"a. Obstruction of the appendix may increase venous drainage and cause the appendix
to rupture.
b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation,
and rupture of the appendix.
c. The appendix may develop gangrene and rupture, especially in a middle-aged client.
d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous
drainage." - Answer-Answer B. A client with appendicitis is at risk for infection related to
inflammation, perforation, and surgery because obstruction of the appendix causes
mucus fluid to build up, increasing pressure in the appendix and compressing venous
outflow drainage. The pressure continues to rise with venous obstruction; arterial blood
flow then decreases, leading to ischemia from lack of perfusion. Inflammation and
bacterial growth follow, and swelling continues to raise pressure within the appendix,
resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially
susceptible to appendix rupture.
"A client is admitted with a diagnosis of acute appendicitis. When assessing the
abdomen, the nurse would expect to find rebound tenderness at which location?
a) Left lower quadrant
b) Left upper quadrant
c) Right upper quadrant
d) Right lower quadrant - Answer-Correct answer: d) Right lower quadrant"
Rationale: The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at
McBurney's point, an area midway between the umbilicus and the right iliac crest. Often,
the pain is worse when manual pressure near the region is suddenly released, a
condition called rebound tenderness.
The nurse is monitoring a client diagnosed with appendicitis who is scheduled for
surgery in 2 hours. The client begins to complain of increased abdominal pain and
begns to vomit. On assessment, the nurse notes that the abdomen is distended and
bowel sounds are diminished. Which is the appropriate nursing intervention? "1. Notify
the Physician
2. Administer the prescribed pain medication
3. Call and ask the operating room team to perform the surgery as soon as possible
4. Reposition the client and apply a heating pad on warm setting to the client's abdomen
- Answer-CORRECT ANSWER: 1"
"1. Based on the assessment information the nurse should suspect peritonitis, a
complication that is associated with appendicitis, and notify the physician.
2. Administering pain medication is not an appropriate intervention
3. Scheduling surgical time is not within the scope of practice of an RN.
4. Heat should never be applied to the abdomen of a patient suspected of having
peritonitis because of the risk of rupture."
, A client is admitted with right lower quadrant pain, anorexia, nausea, low-grade fever,
and elevated white blood cell count. Which complication is most likely the cause? 1. A.
fecalith 2. Bowel Kinking 3. Internal blowel occlusion 4. Abdominal wall swelling -
Answer-"Answer 1
Rational: The client is experiencing appendicitis. A. fecalith is a fecal calculus, or stone,
that occludes the lumen of the appendix and is the most common cause of appendicitis.
Bowel wall swelling, kinking of the appendix, and external occlusion not internal
occlusion, of the bowel by adhesions can also be cause of appendicitis."
"A client with acute appendicitis develops a fever, tachycardia, and
hypotension. Based on these assessment findings, the nurse should
further assess the client for which of the following complications?...
"1. Deficient fluid volume.
2. Intestinal obstruction.
3. Bowel ischemia.
4. Peritonitis - Answer-Correct 4
"Complications of acute appendicitis are perforation, peritonitis, and
abscess development. Signs of the development of peritonitis include
abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting,
and fever. Because peritonitis can cause hypovolemic shock, hypotension
can develop. Deficient fluid volume would not cause a fever. Intestinal
obstruction would cause abdominal distention, diminished or absent
bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms
similar to those found with intestinal obstruction."
"The client diagnosed with appendicitis has undergone an appendectomy. At two hours
postoperative, the nurse takes the vital signs and notes T 102.6 F, P 132, R 26, and BP
92/46. Which interventions should the nurse implement? List in order of priority.
1. Increase the IV rate.
2. Notify the health care provider.
3. Elevate the foot of the bed.
4. Check the abdominal dressing.
5. Determine if the IV antibiotics have been administered. - Answer-Order of priority: 1,
3, 4, 5, 2."
"1. The nurse should increase the IV rate to maintain the circulatory system function
until further orders can be obtained.
3. The foot of the bed should be elevated to help treat shock, the symptoms of which
include elevated pulse and decreased BP. Those signs and an elevated temperature
indicate an infection may be present and the client could be developing septicemia.
4. The dressing should be assessed to determine if bleeding is occurring.
5. The nurse should administer any IV antibiotics ordered after addressing hypovolemia.
The nurse will need this information when reporting to the HCP.
2. The HCP should be notified when the nurse has the needed information."
"During the assessment of a patient with acute abdominal pain, the nurse should:
a. perform deep palpation before auscultation
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