Appendicitis NCLEX
"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." - ANS-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 A. 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. - ANS-The nurse is admitting a client with the diagnosis of appendicitis to the
surgical unit. Which question is essential to ask? A."When did you last eat?" B."Have you had
surgery before?" C."Have you ever had this type of pain before?" D."What do you usually take
to relieve your pain?"
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. - ANS-"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 D. 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 - ANS-Which of the nursing interventions should be implemented to
manage appendicitis?
, a. Assess pain b. encourage oral intake of clear fluids. c. provide discharge teaching D. assess
for symptoms of peritonitis.
Answer: 4
Rationale: A tense, rigid abdomen is an early symptom of peritonitis. The other findings are
expected in the immediate postoperative period. - ANS-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.
1. abdominal pain, 2. tugging at the incision line, 3. thirst, 4 a rigid abdomen
Answer: D
"D) 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." - ANS-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?
"a) Hematocrit 42%
b) Serum potassium 4.2 mEq/L
c) Serum sodium 135 mEq/L
d) White blood cell (WBC) count 22.8/mm3.
Answer: D
Rationale: 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. - ANS-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:""a) administer saline enemas to cleanse the bowels
b) apply heat to reduce pain
c) measure abdominal girth
d) continuously monitor pain
C. Semi-fowlers aids in drainage and prevents spread of infection throughout the abodominal
cavity. - ANS-A client has surgery for a perforated appendix with localized peritonis. In which
position should the nurse place the client?
A) Sims position B) trendelenburg C) semi-fowlers D)dorsal recumbant
C) rebound tenderness is a classic subjective sign of appendicitis - ANS-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
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