NCLEX PRACTICE QUESTIONS SAUNDERS QUESTIONS WITH CORRECT ANSWERS

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the health care provider (HCP). 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 the warm setting to the client's abdomen. CORRECT ANSWER 1. Notify the health care provider (HCP). Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time. A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1. Burning and aching, located in the left lower quadrant and radiating to the hip 2. Severe and unrelenting, located in the epigastric area and radiating to the back 3. Burning and aching, located in the epigastric area and radiating to the umbilicus 4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin CORRECT ANSWER 2. Severe and unrelenting, located in the epigastric area and radiating to the back Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain?