APPENDICITIS

1. A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A
drain was inserted into the incisional site during surgery. Which action should the nurse perform
when providing wound care?

Clean the area around the drain moving away from the drain.

The nurse should gently clean the area around the drain by moving in a circular motion away from the
drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision
cannot be left open to air as long as the drain is intact. The nurse should note the amount and character
of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound
drains are not irrigated.

2.The nurse is admitting a client with acute appendicitis to the emergency department. The client has
abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible.
The nurse should:

Place the client on nothing-by-mouth (NPO) status.

The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain
relief strategies, such as relaxation techniques, but the surgeon will likely not order narcotic medication
prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat
is contraindicated because it may lead to perforation of the appendix.

3.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?

Peritonitis.

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.

4.Postoperative nursing care for a client after an appendectomy should include which of the
following?

Noting the first bowel movement after surgery.

Noting the client's first bowel movement after surgery is important because this indicates that normal
peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is
started the day of surgery and is not confined to bathroom privileges. The abdomen should be
auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every
2 hours.
5. A client who had an appendectomy for a perforated appendix returns from surgery with a drain
inserted in the incisional site. The purpose of the drain is to:

2. Promote drainage of wound exudates.

Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix
was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A
drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or
decrease postoperative discomfort.

6. The nurse would increase the comfort of the patient with appendicitis by:

Flexing the patient's right knee

The patient with appendicitis usually prefers to lie still, often with the right leg flexed to decrease pain.

7."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?

Rovsing sign

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.

8.Which of the following position should the client with appendicitis assume to relieve pain ?

Lying with legs drawn up

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

9.When evaluating a male client for complications of acute pancreatitis, the nurse would observe for:

decreased urine output

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."
10."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?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the
appendix.

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.

11.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?

Right lower quadrant

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.

12.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?

Notify the Physician

Based on the assessment information the nurse should suspect peritonitis, a complication that is
associated with appendicitis, and notify the physician.

13.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?

A. fecalith

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."
14."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?...

Peritonitis

"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."

15."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.

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.
16."During the assessment of a patient with acute abdominal pain, the nurse should:

measure body temperature because an elevated temperature may indicate an inflammatory or

infectious process

for the patient complaining of acute abdominal pain, nurse should take vital signs immediately.
Increased pulse and decreasing blood pressure are indicative of hypovolemia. An elevated temperature
suggests an inflammatory infectious process. Intake and output measurements provide essential
information about the adequate of vascular volume. Inspect abdomen first and then auscultate bowel
sounds. Palpation is performed next and should be gentle.

17.A client complains of severe pain in the right lower quadrant of the abdomen. To assist with pain
relief, the nurse should take which of the following actions?

Use comfort measures and pillows to position the client

1. Encourage the client... - unnecessary movement will increase pain and should be avoided

2. Massage the lower...- if appendicitis is suspected, massage or palpation should never be performed as
these actions may cause the appendix to rupture

3. Apply warmth... - if pain is caused by appendicitis, increased circulation from the heat may cause
appendix to rupture

4. Use comfort measures... - CORRECT: non-pharmacological methods of pain relief"

18."A nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute
appendicitis. Which of the following laboratory results would the nurse expect to note if the client
does have appendicitis?

Leukocytosis with a shift to the right

19.An 18 yr old is admitted with an acute onset of right lower quadrant pain. Appendicitis is
suspected. For which clinical indicator should the nurse assess the client to determine if the pain is
secondary to appendicitis

rebound tenderness

rebound tenderness is a classic subjective sign of appendicitis

20.Which client requires immediate nursing intervention? "The client who:

presents with a rigid, boardlike abdomen.

A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain
occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain
are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases
significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools.

21."The nurse is admitting a client with acute appendicitis to the emergency department. The client
has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as
possible. The nurse should:

Place the client on nothing-by-mouth (NPO) status.

22.A client has surgery for a perforated appendix with localized peritonis. In which position should the
nurse place the client?

semi-fowlers

Semi-fowlers aids in drainage and prevents spread of infection throughout the abdominal cavity.

23.A nurse is making a home health visit and finds the client experiencing right lower quadrant
abdominal pain, which has decreased in intensity over the last day. The client also has a rigid
abdomen and a temperature of 103.6 F. The nurse should intervene by:

notifying the physician

The client symptoms indicate appendicitis which requires immediate attention

24.The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which
question is essential to ask?

"When did you last eat?"

When a person is admitted with possible appendicitis, the nurse should anticipate surgery. It will be
important to know when she last ate when considering the type of anesthesia so that the chance of
aspiration can be minimized. The other inoformation is "nice to know", but not essential.

25.Which of the nursing interventions should be implemented to manage appendicitis?

assess for symptoms of peritonitis.

Monitor for peritonitis because if the appendix ruptures, bacteria can enter the peritoneum. Pain will be
managed with analgesics, and pt should be NPO for surgery. Discharge is not done at this time
26.A client with complaints of right lower quadrant pain is admitted to the emergency department.
Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported
to the physician immediately?

White blood cell (WBC) count 22.8/mm3.

The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that
the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and
serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate
appendicitis."

27.The doctor ordered for a complete blood count. After the test, Nurse Ray received the result from
the laboratory. Which laboratory values will confirm the diagnosis of appendicitis?

WBC 13, 000/mm3

Increase in WBC counts is suggestive of appendicitis because of bacterial invasion and inflammation.
Normal WBC count is 5, 000 - 10,000/mm3. Other options are normal values."

28.A school-aged child has an emergency appendectomy. The nurse should report which of the
following to the HCP if notes in the immediate postoperative period.

a rigid abdomen

A tense, rigid abdomen is an early symptom of peritonitis. The other findings are expected in the
immediate postoperative period.

29."A client has an appendectomy and develops peritonitis. The nurse should asses the client for an
elevated temperature and which additional clinical indication commonly associated with peritonitis?

local muscular rigidity

muscular rigidity over the affected area is a classic sign of peritonitis

30.A nurse is caring for a child who had a laproscopic appendectomy. What interventions should the
nurse document on the child's clinical record? Select all that apply.

1) Intake and Output 2) Measurement of Pain 3) Tolerance to low-residue diet 4) Frequency of dressing
changes 5) Auscultation of bowel sounds

Answer: 1, 2, 5

1) Assessment and documentation of fluid balance are critical aspects of all postoperative care. 2)
Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is
absorbed. The amount of pain should be measured and documented with either a 1-10 scale or the
Wong's FACES for younger children. 3) A special diet is not indicated after this surgery. 4) After a
laparoscopic appendectomy there is little drainage and no dressings. 5) Auscultating for bowel sounds
and documenting their presennce or absence evaluate the child's adaptation to the intestinal trauma
caused by the surgery.

31.The nurse is assessing an adolescent who is admitted to the hospital with appendicitis. The nurse
should report which of the following to the HCP?

sudden relief of sharp pain, shifting to diffuse pain

The nurse notifies the HCP if the client has sudden relief of sharp pain and on presence of more diffuse
pain. this change in the pain indicates the appendix has ruprured. The diffuse pain is typically
accompanied by rigid guarding of the abdomen, progressive abdominal distension, tachycardia, pallor,
chills, and irritability. The slight increase pain can be expected; the decrease in pain when parents visit
may be attributed to being distracted from the pain. shallow breathing is likely due to the pain and is
insignificant when other vital signs are normal

32.Bobby, a 13 year old is being seen in the emergency room for possible appendicitis. An important
nursing action to perform when preparing Bobby for an appendectomy is to:

continuously monitor pain

Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to
surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A
sudden change in the character of pain may indicate rupture or bowel perforation. Administering an
enema or applying heat may cause perforation and abdominal girth may not change with appendicitis.

33.which statement made by the client who is postoperative abdominal surgery indicates the
discharge teaching has been effective?

i will take all of my antibiotics until they are gone

this statement about taking all the antibiotics ordered indicates the teaching is effective.

34.Which of the following would confirm a diagnosis of appendicitis?

The pain is localized at a position halfway between the umbilicus and the right iliac crest.

"Pain over McBurney's point, the point halfway between the umbilicus and the iliac crest, is diagnosis
for appendicitis. Options b and c are common with ulcers; option d may suggest ulcerative"
35.Which of the following would indicate that Bobby's appendix has ruptured? "

relief from pain

all are normal signs of having appendicitis and once you have relief from pain means you could have a
rupture.

36.Which of the following complications is thought to be the most common cause of appendicitis?

A fecalith

A fecalith is a hard piece of stool which is stone like that commonly obstructs the lumen. Due to
obstruction, inflammation and bacterial invasion can occur. Tumors or foreign bodies may also cause
obstruction."

37.The client with severe abdominal pain is being evaluated for appendicitis. What is the most
common cause of appendicitis?

Obstruction of the appendix

Appendicitis most commonly results from obstruction of the appendix, which may lead to rupture.

38."The nurse is caring for a patient following an appendectomy. The patient takes a deep breath,
coughs, and then winces in pain. Which of the following statements, if made by the nurse to the
patient, is BEST?

"Take three deep breaths, hold your incision, and then cough."

most effective way of deep breathing and coughing, dilates airway and expands lung surface area

39.Unless contraindicated by the surgical procedure, which position is preferred for the unconscious
patient immediately postoperative?

Lateral

Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral
"recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if
the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of
the bed elevated.

40.The nurse is working on a surgical floor and is preparing to receive a postoperative patient from
the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's
arrival?
B) Assess the patient's vital signs.

The highest priority action by the nurse is to assess the physiologic stability of the patient. This is
accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid
sequence.

41When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new,
bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do
first?

Assess the patient's blood pressure and heart rate.

The first action by the nurse is to gather additional assessment data to form a more complete clinical
picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency
policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

42.In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep
breathing, which action should the nurse recognize will best enable the patient to achieve the desired
outcomes?

Administering adequate analgesics to promote relief or control of pain.

Even when a patient understands the importance of postoperative activities and demonstrates them
correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to
cooperate with the activities.

43.In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care
can be delegated to the unlicensed assistive personnel (UAP)?

Assist the patient to take deep breaths and cough.

The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report
complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the
patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's
pain and change the dressings.

44.The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300
mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse
anticipate for this patient?

Restoring circulating volume

The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used
to restore circulating volume, there are no manifestations in this patient indicating a need for blood
administration. An ECG may be done if there is no response to the fluid administration, or there is a past
history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check
for internal bleeding would only be done if patient's level of consciousness changes or the abdomen
becomes firm and distended.

45.A 67-year-old male patient is admitted to the post anesthesia care unit (PACU) after abdominal
surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression?

Increased carbon dioxide pressure

Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory

depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of
inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular
contractions), and decreased oxygen saturation.

46.The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the
post anesthesia care unit after abdominal hysterectomy. How should the nurse position the patient?

Left lateral position with head supported on a pillow

The unconscious patient should be placed in the lateral "recovery" position to keep the airway open and
reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with
the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the
abdominal contents on the diaphragm.

47.When a patient is admitted to the PACU, what are the priority interventions the nurse performs?

Assess for airway patency and quality of respirations, and obtain vital signs

Assessment in the post anesthesia care unit (PACU) begins with evaluation of the airway, breathing, and
circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or
respiratory compromise necessitates prompt intervention.

48.A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the
patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to:

position patient in lateral recovery position.

If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the
airway open and reduce the risk of aspiration if vomiting occurs.
49.After admission of the postoperative patient to the clinical unit, which assessment data requires
the most immediate attention?

Oxygen saturation of 85%

During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry
monitoring is initiated because it provides a noninvasive means of assessing the adequacy of
oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory
compromise. This necessitates prompt intervention.

50.A 70kg postoperative patient has an average urine output of 25mL/hr during the first 8 hours. The
priority nursing intervention(s) given this assessment would be to:

evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.

Because of the possibility of infection associated with catheterization, the nurse should first try to
validate that the bladder is full. The nurse should consider fluid intake during and after surgery and
should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound
study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

51.Which of the following nursing interventions should receive highest priority when a patient is
admitted to the postanesthesia care unit?

Positioning the patient

A patient is received in the postanesthesia care unit on a bed or stretcher. Proper positioning is
necessary to ensure airway patency in a sedated, unconscious, or semiconscious patient. Observation of
the operative site, receiving report from operating room personnel, and checking postoperative orders
are interventions made after proper positioning of the patient.

52.In the operating room, a patient tells a circulating nurse that he is going to have the cataract in his
left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed
on the right eye, what should be the nurse's first action?

Ask the patient his name.

Ensuring proper identification of a patient is a responsibility of all members of the surgical team. In a
specialty surgical setting where many patients undergo the same type of surgery each day, such as
cataract removal, it is possible that the patient and the record do not match. Nurses do not assume in
the care of their patients. The priority is with the nurse identifying the patient and the patient's consent
form before the physicians are notified.

53.What would be the most effective way for a nurse to validate "informed consent"?
Ask the patient what he or she understands regarding the procedure.

Informed consent in the health care setting is a process whereby a patient is informed of the risks,
benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The piece of
paper is simply evidence that the informed consent process has been done.

54While a nurse is caring for a patient who is scheduled to have surgery in 2 hours, the patient states,
"My doctor was here and told me a lot of stuff I didn't understand and then I signed a paper for her."
To fulfill the role of advocate, what is the best nursing action?

Call the physician to return and clarify information for the patient.

Examples of nursing advocacy include questioning doctors' orders, promoting patient comfort, and
supporting patient decisions regarding health care choices.

55.To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious,
the nurse

positions the patient in a side-lying position.

An unconscious or semiconscious patient should be placed in a lateral position to protect the airway
from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented
to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the
patient must first have a patent airway.

56.In the absence of postoperative vomiting, GI suctioning, and wound drainage, the physiologic
responses to the stress of surgery are most likely to cause

fluid overload.

Secretion and release of aldosterone and cortisol from the adrenal gland and ADH from the posterior
pituitary as a result of the stress response cause fluid retention during the first 2 to 5 days
postoperatively, and fluid overload is possible during this time. Aldosterone causes renal potassium loss
with possible hypokalemia, and blood coagulation is enhanced by cortisol.

57.Select all that apply. Which of the following best describes a consent form?

May be signed by an emancipated minor.

Signifies that the patient understands all aspects of the procedure.

A consent form may be signed by an emancipated minor, and consent may be obtained by fax or phone
with appropriate witnesses. Only in the cases of underage children or unconscious or mentally
incompetent people must a family member be aware of the procedure. The document protects the
surgeon and the health care facility in that it indicates that the patient knows and understands all
aspects of the procedure.

58.Select all that apply. A nurse is caring for a surgical patient in the preoperative area. The nurse
obtains the patient's informed consent for the surgical procedure. Which statements are true
regarding informed consent?

Informed consent must be signed while the patient is free from mind-altering medications.
Informed consent must be witnessed.

An informed consent must be signed while the patient is free from mind-altering medications and must
be witnessed after it has been determined that the patient has received all of the necessary information
needed to make an informed decision. An informed consent may be withdrawn at any time before the
procedure and must be signed by patients age 18 and older. A parent or guardian's signature is required
for minors. The informed consent may be obtained by the physician or the nurse and is not required in
the event of a life-threatening emergency.

59.What are some common Nursing Interventions to reduce risk/avoid post-op complications?

1. Turn & reposition the pt to promote circulation and reduce the risk of skin breakdown, especially over
boney prominences.

Initially position pt in a Lateral recumbant position until arousal from anesthesia, then position pt in
Semi or Fowler position to reduce breathing effort.

2. Encourage coughing & deep breathing.

This helps clear anestetics from the body, lowers risk of pulmonary/fat emboli, and hypostatic
pneumonia associated with secretion buildup in the airways.

3. Encourage use of Incentive Spirometer.

4. Monitor In's and Out's.

Hydration and protein rich nutrition promotes healing and provides energy to meet the needs of the pts
increased metabolism associated with surgery.

5. Promote early ambulation. Early post-op exercise and ambulation significantly reduce the risk of
thromboembolism.

60.The reason pts are sent to a PACU after surgery is:

to be monitored while recovering from anesthesia.

Pts are sent to a PACU to be monitored while they're recovering from anesthesia.

61.Patients may experience which problem 24-48 hrs post-op as a result of anesthetics?

Paralytic ileus

After surgery, pts are clients are at risk for paralytic ileus as a result of anesthesia.

62.The nurse is preparing to send a patient to the operating room for an exploratory laparoscopy. The
nurse recognizes that there is no informed consent for the procedure on the patient's chart. The nurse
informs the physician who is performing the procedure. The physician asks the nurse to obtain the
informed consent signature from the patient. The nurse's best action to the physician's request is to:

Inform the physician that is his responsibility to obtain the signature.

The responsibility for securing informed consent from the patient lies with the person who will perform
the procedure. The nurse's best action is to inform the physician that it is his responsibility to obtain the
signature.

63.The PACU has received a semiconscious patient from the operating room and reviews the chart for
orders related to positioning of the patient. There are no specific orders on the chart related to
specific orders for the patient's position. In this situation, in what position will the nurse place the
patient?

Side-lying position

If the patient is not fully conscious, place the patient in the side-lying position, unless there is an ordered
position on the patient's chart.

64.A patient returning to the floor after orthopedic surgery is complaining of nausea. The nurse is
aware that an appropriate intervention is to:

Avoid strong smelling foods.

Nursing care for a patient with nausea includes avoiding strong smelling foods. Providing oral hygiene,
administering prescribed medications (especially if medications ordered are anti-nausea/antiemetics),
and avoid the use of a straw.

65. A client telephones the health clinic with complaints of generalized abdominal pain which is
aggravated by moving or walking. The client has not been able to eat for a day and is nauseated.
Which advice should the nurse provide to this client?

Seek immediate medical attention

The initial characteristic manifestation of acute appendicitis is continuous, mild, generalized or upper
abdominal pain. Over the next 4 hours, the pain intensifies and localizes in the right lower quadrant of
the abdomen. Pain associated with appendicitis is aggravated by moving, walking, or coughing. If
medical attention is not provided, gangrene can develop within 24dash36 hours. The client should be
instructed to seek immediate medical attention. Resting in bed and drinking warm fluids is not going to
prevent the appendix from developing gangrene. When appendicitis is suspected, the client should be
instructed to avoid laxatives and not to apply heat to the abdomen because heat could encourage the
appendix to rupture.

66.Which clinical manifestation does the nurse expect with acute appendicitis?

Rebound tenderness

One manifestation of acute appendicitis is localized and rebound tenderness of McBurney point upon
palpation. A high fever is a manifestation of a perforated appendix. Nausea and vomiting are generalized
symptoms and are not present exclusively with appendicitis. Ambulation increases pain in appendicitis.

67.Which condition may occur if the client does not seek medication attention for acute appendicitis
within 24dash36 hours? (Select all that apply.)

Peritonitis
Perforation

If treatment is not initiated, tissue necrosis and gangrene result within 24-36 hours, leading to
perforation (rupture). Perforation allows the contents of the gastrointestinal (GI) tract to flow into the
peritoneal space of the abdomen, resulting in peritonitis. Appendicitis does not cause seizures, nausea,
or constipation.

68.A teenage boy presents with suspected appendicitis. The caregiver asks, "Why did my son get
this?" Which response by the nurse is the most appropriate?

"Your adolescent son is in a risk group."

Adolescent boys are at greatest risk for appendicitis. Appendicitis cannot be prevented, but certain
dietary habits may reduce the risk of developing this condition. Eating foods that contain high fiber
content, such as fresh fruits and vegetables, decreases the incidence of appendicitis.
69.Appendicitis almost always results from an obstruction in the appendiceal lumen. Which problem
should the nurse identify as the cause of this obstruction?

Fecalith

The obstruction is often caused by a hard mass of feces (fecalith). Ptyalith is a calculus in the salivary
gland. Tonsillolith is a calculus in the tonsil. A monolith is a large stone used in sculpture.

70.Which statement by a client diagnosed with acute appendicitis leads the nurse to believe the client
needs teaching about dietary interventions?

"I don't like fruits and vegetables."

Certain dietary habits may reduce the risk of developing acute appendicitis. Eating foods that contain
high fiber content, such as fresh fruits and vegetables, decreases the incidence of appendicitis.

71.Which assessment finding leads the nurse to suspect that an older client may have appendicitis?
(Select all that apply.)

Tenderness when pressing McBurney point

Confusion
Internal rotation of the left hip increases pain

Fewer than 30% of older adults who have appendicitis present with classic symptoms. Classic signs of
acute appendicitis are pain that is aggravated by moving or walking, rebound tenderness of McBurney
point, and extension or internal rotation of the right hip that increases pain and confusion. A little less
than half demonstrate no rebound or involuntary guarding. Pain typically migrates down to the lower
right quadrant in appendicitis.

72.A teenage girl is being assessed for the possibility of appendicitis. Which other condition should the
nurse consider? (Select all that apply.)

Pelvic inflammatory disease

Ovulation
Ruptured ectopic pregnancy

In adolescent and young women, symptoms must be differentiated from those associated with
ovulation, ruptured ectopic pregnancy and pelvic inflammatory disease. Although a urinary tract
infection may cause abdominal pain, it typically does not present in the same way as appendicitis.
Menstruation does not have the same symptoms as appendicitis.
73.Appendicitis in a pregnant woman is a complex problem. Which statement is true based on the
given premise?

A. Appendicitis is the most common surgical presentation in pregnant women.

B. Appendicitis does not occur in pregnant women.

C. Appendicitis will cause fetal death.

D. A pregnant woman will have surgery postpartum.

Rationale: Acute appendicitis is the most common surgical presentation in pregnant women. It can be
successfully managed by the surgical and obstetrical teams. A recent study has found that appendicitis
during pregnancy can be managed successfully without any dangerous fetal outcomes.

74.A client presents with suspected appendicitis. The nurse should prepare the client for which
collaborative intervention?

A. Chest x-ray

B. Abdominal ultrasound

C. Electrolytes

D. Complete blood count (CBC)

Rationale: Abdominal ultrasound is the most effective test for diagnosing acute appendicitis. Electrolyte
testing provides information relating to the mineral balance in the body. A CBC would be drawn, but it is
not a definitive test to diagnose acute appendicitis. Chest x-rays are not used to diagnose abdominal
conditions.

75.For which collaborative therapy for peritonitis following a ruptured appendix should the nurse
prepare the client? (Select all that apply.)

A. Antibiotics

B. A low-fat, high-calorie diet

C. Passive range of motion

D. Fluid resuscitation

E. Surgery

Answer: A, D, E

Rationale: Clinical therapies for the treatment of peritonitis include removal of the ruptured appendix,
antibiotics, and fluid resuscitation. A low-fat, high-calorie diet and passive range of motion are not
therapies used to treat peritonitis after a ruptured appendix.
76.The nurse is caring for a client admitted for a ruptured appendix. Which information should the nurse
expect to provide to this client? (Select all that apply.)

A. A laparotomy will be performed.

B. Intravenous fluids will be provided.

C. Antibiotic medication will be provided before and after the surgery.

D. Pain medication will be provided after the surgery.

E. A laparoscopic appendectomy will be performed.

Answer: A, B, C, D

Rationale: For a ruptured appendix, a laparotomy will be performed. The client will receive antibiotics
before and after the surgery to prevent the development of infection from fecal contents, which have
spilled into the abdominal cavity. Intravenous fluids will be provided to maintain fluid and electrolyte
balance. Pain medication will be provided after the surgery. A laparoscopic appendectomy is performed
for clients whose appendix has not ruptured.

77.Which condition prompts the nurse to recommend a clear liquid diet to a post appendectomy
client?

A. Client denies any nausea

B. Client no longer reports pain

C. Client is afebrile

D. Client's bowel sounds have returned

Rationale: Once bowel sounds return, a client can begin taking clear fluids. The postoperative client is
expected to be afebrile. Pain will subside as healing continues. Nausea would be subsided for the client
to resume a PO diet, but it is the presence of bowel sounds that would indicate the gastrointestinal
tract's ability to handle digestion.

78.A client had a laparoscopic appendectomy last night. Which assessment finding should concern the
nurse?

A. Dry wound

B. Adequate fluid intake

C. Pain

D. Fever
Rationale: Fever would be an indication of a possible infection. Postoperative pain is expected.
Adequate fluid intake and a dry wound are positive recovery signs.

79.For which intervention are African American children with appendicitis less likely to receive in the
emergency department?

A. IV fluids

B. Adequate pain medication

C. Postoperative teaching

D. Surgical intervention

Rationale: African American children are less likely to receive adequate medication in emergency
departments for pain during episodes of appendicitis. Nurses should advocate for appropriate pain
management for all clients.

80.A client with acute appendicitis asks the nurse, "Why don't you give me a heating pad? I think that
will help me with my pain." The nurse's response should be based on which reason?

A. It increases the need for fluids.

B. It increases the spread of infection.

C. It reduces white blood cell count.

D. It encourages perforation.

Rationale: Heat should not be applied to the abdomen since this increases circulation to the appendix
and could cause perforation. It is not true that heat is avoided in acute appendicitis because it increases
the need for fluids, increases the spread of infection, or reduces white blood cell count.

81.A client is admitted with acute appendicitis. Which nursing diagnosis may be appropriate for this
client? (Select all that apply.)

A. Nutrition, Imbalanced: Less than Body Requirements

B. Fluid Volume: Deficit, Risk for

C. Tissue Perfusion: Peripheral, Ineffective

D. Infection, Risk for

E. Pain, Acute
Rationale: A client with acute appendicitis would experience pain at the site. Any patient who has
undergone surgery is at risk for fluid depletion and infection of the wound. Nutritional status and change
in peripheral perfusion are not nursing problems appropriate for the client with appendicitis.

82.The nurse is providing discharge teaching to a client who is recovering from an uncomplicated
appendectomy. Which information should the nurse include? (Select all that apply.)

A. Caring for the wound

B. Recognizing manifestations of infection

C. Increasing physical activity

D. Notifying the healthcare provider with changes

E. Avoiding nonsteroidal anti-inflammatory drugs (NSAID)

Rationale: The client with uncomplicated appendectomy is often discharged home the day of the
surgery or the day after. Postoperative teaching includes wound care, including hand hygiene and
dressing changes as indicated; to report to the healthcare provider fever, increased abdominal pain,
swelling, redness, drainage, bleeding, or warmth of the operative site; activity limitations (e.g., lifting);
and return to work if appropriate. The client can take NSAIDs for pain.

83.The nurse is evaluating a client recovering at home after an emergency appendectomy. Which
observation indicates that self-care has been effective? (Select all that apply.)

A. The client snacks on pretzels and club soda during the visit.

B. The client plans to recover at home until cleared by the surgeon.

C. The client uses a pillow to splint the incision before coughing.

D. The client performs abdominal wound care appropriately.

E. The client requests a prescription for more pain medication.

Answer: B, C, D

Rationale: Observations that indicate that the client is appropriately providing self-care after an
appendectomy include using a pillow to splint the incision before coughing, performing wound care
appropriately, and planning to recover at home until cleared by the surgeon. Observations that indicate
that self-care could improve include the need for more pain medication and ingesting a less-than-
nutritious snack.
84.The nurse is preparing to conduct a physical examination on a client diagnosed with appendicitis.
Which intervention should the nurse include in this assessment? (Select all that apply.)

A. Characteristics of bowel sounds

B. Presence of abdominal pain on palpation

C. Presence of blood in the stool

D. Contour of the abdomen

E. Current body temperature

Rationale: When conducting the physical assessment on a client with appendicitis, the nurse should
include abdominal contour, current body temperature, characteristics of bowel sounds, and whether
the client is experiencing tenderness to light palpation. Blood in the stool is not an area to assess in the
client with appendicitis.