A client with acute appendicitis develops a fever, tachycar- peritonitis
dia, and hypotension. Based on these findings, the nurse
should further assess the client for which complication? *Complications of acute appendicitis are perforation,
peritonitis, and abscess development. Signs of the devel-
bowel ischemia opment of peritonitis include abdominal pain and dis-
deficient fluid volume tention, tachycardia, tachypnea, nausea, vomiting, and
intestinal obstruction fever. Because peritonitis can cause hypovolemic shock,
peritonitis hypotension can develop.
surgery
A client with appendicitis is experiencing excruciating ab-
dominal pain. An abdominal X-ray film reveals intraperi- *The client should be prepared for surgery because the
toneal air. What should the nurse prepare the client for? signs and symptoms indicate bowel perforation. Appen-
dicitis is a common cause of bowel perforation. Because
surgery
perforation can lead to peritonitis and sepsis, surgery
colonoscopy
would not be delayed to perform other interventions, such
nasogastric (NG) tube insertion
as colonoscopy, NG tube insertion, or a barium enema.
barium enema
These procedures are not necessary at this point.
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. What should the
nurse do next?
Place the client on nothing-by-mouth (NPO) status.
Apply heat to the abdomen in the area of the pain.
Maintain the client in a recumbent position.
Contact the surgeon to request a prescription for a nar-
cotic for the pain.
Place the client on nothing-by-mouth (NPO) status.
a registered nurse pulled from the cardiac unit.
*According to the National Council of State Boards of
, Nursing, delegation encompasses five rights — the right
task, right circumstance, right person, right direction and
A nurse is assigning the care of a client admitted with communication, and right supervision and evaluation. This
appendicitis. The nurse should assign this client's care to: client requires frequent assessment and monitoring. The
nurse should assign the client's care to a registered nurse
a registered nurse pulled from the cardiac unit. because the client may need immediate nursing action
a licensed practical nurse with pediatric experience. if the appendix ruptures. The client does not require the
a registered nurse with geriatric experience. specialized knowledge of a clinical nurse specialist. It is
a graduate nurse awaiting N-CLEX results. not appropriate to delegate the licensed practical nurse.
Since appendicitis is uncommon in the elderly population,
the cardiac nurse would be a better choice.
The nurse is assessing a client who has cholecysti-
nausea after ingestion of high-fat foods
tis caused by gallstones (cholelithiasis). Which finding
should the nurse report to the health care provider? *A client with cholecystitis from cholelithiasis may experi-
ence nausea, vomiting, abdominal discomfort, and other
elevated temperature of 103°F (39.4°C)
gastrointestinal symptoms after eating high-fat foods. This
black stools
is due to decreased fat absorption related to a lack of
decreased white blood cell count
normal bile flow from the gallbladder.
nausea after ingestion of high-fat foods
Administer pain medication.
The nurse in the emergency department is admitting a *Administering pain medication would have the highest
client with cholecystitis who is experiencing pain and nau- priority during the first hour after the client's admission.
sea. Which action should the nurse take first? Completing the admission history can be done after the
Administer an oral electrolyte solution. client's pain is controlled.
Administer pain medication. Maintaining hydration is important but likely will be ad-
Finish obtaining a complete admission history. ministered intravenously since the client is nauseated.
Tell the client about planned diagnostic tests. It is not appropriate to try to teach while a client is in pain.
Teaching about planned diagnostic tests can occur after
the client is comfortable.
dia, and hypotension. Based on these findings, the nurse
should further assess the client for which complication? *Complications of acute appendicitis are perforation,
peritonitis, and abscess development. Signs of the devel-
bowel ischemia opment of peritonitis include abdominal pain and dis-
deficient fluid volume tention, tachycardia, tachypnea, nausea, vomiting, and
intestinal obstruction fever. Because peritonitis can cause hypovolemic shock,
peritonitis hypotension can develop.
surgery
A client with appendicitis is experiencing excruciating ab-
dominal pain. An abdominal X-ray film reveals intraperi- *The client should be prepared for surgery because the
toneal air. What should the nurse prepare the client for? signs and symptoms indicate bowel perforation. Appen-
dicitis is a common cause of bowel perforation. Because
surgery
perforation can lead to peritonitis and sepsis, surgery
colonoscopy
would not be delayed to perform other interventions, such
nasogastric (NG) tube insertion
as colonoscopy, NG tube insertion, or a barium enema.
barium enema
These procedures are not necessary at this point.
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. What should the
nurse do next?
Place the client on nothing-by-mouth (NPO) status.
Apply heat to the abdomen in the area of the pain.
Maintain the client in a recumbent position.
Contact the surgeon to request a prescription for a nar-
cotic for the pain.
Place the client on nothing-by-mouth (NPO) status.
a registered nurse pulled from the cardiac unit.
*According to the National Council of State Boards of
, Nursing, delegation encompasses five rights — the right
task, right circumstance, right person, right direction and
A nurse is assigning the care of a client admitted with communication, and right supervision and evaluation. This
appendicitis. The nurse should assign this client's care to: client requires frequent assessment and monitoring. The
nurse should assign the client's care to a registered nurse
a registered nurse pulled from the cardiac unit. because the client may need immediate nursing action
a licensed practical nurse with pediatric experience. if the appendix ruptures. The client does not require the
a registered nurse with geriatric experience. specialized knowledge of a clinical nurse specialist. It is
a graduate nurse awaiting N-CLEX results. not appropriate to delegate the licensed practical nurse.
Since appendicitis is uncommon in the elderly population,
the cardiac nurse would be a better choice.
The nurse is assessing a client who has cholecysti-
nausea after ingestion of high-fat foods
tis caused by gallstones (cholelithiasis). Which finding
should the nurse report to the health care provider? *A client with cholecystitis from cholelithiasis may experi-
ence nausea, vomiting, abdominal discomfort, and other
elevated temperature of 103°F (39.4°C)
gastrointestinal symptoms after eating high-fat foods. This
black stools
is due to decreased fat absorption related to a lack of
decreased white blood cell count
normal bile flow from the gallbladder.
nausea after ingestion of high-fat foods
Administer pain medication.
The nurse in the emergency department is admitting a *Administering pain medication would have the highest
client with cholecystitis who is experiencing pain and nau- priority during the first hour after the client's admission.
sea. Which action should the nurse take first? Completing the admission history can be done after the
Administer an oral electrolyte solution. client's pain is controlled.
Administer pain medication. Maintaining hydration is important but likely will be ad-
Finish obtaining a complete admission history. ministered intravenously since the client is nauseated.
Tell the client about planned diagnostic tests. It is not appropriate to try to teach while a client is in pain.
Teaching about planned diagnostic tests can occur after
the client is comfortable.
