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Appendicitis NCLEX Exam Questions and Answers
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Appendicitis NCLEX Exam Questions and Answers
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Appendicitis NCLEX Exam Questionsand Answers
"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."
"During the assessment of a patient with acute abdominal pain, the nurse should:
a. perform deep palpation before auscultation
b. obtain blood pressure and pulse rate to determine hypervolemic changes
c. auscultate bowel sounds because hyperactive bowel sounds suggest paralytic ileus
d. measure body temperature because an elevated temperature may indicate an
inflammatory or infectious process. - Answer-Correct D
Rationale: 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.
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? "1. Encourage the
client to change positions frequently in bed
2. Massage the right lower quadrant fo the abdomen
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