APPENDICITIS NCLEX EXAM
QUESTIONS AND ANSWERS
"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
3. Apply warmth to the abdomen with a heating pad
4. Use comfort measures and pillows to position the client" - Answer-Correct 4
"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 the 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"
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
A) urinary retention B) gastric hyperacidity C) rebound tenderness D) increased lower
bowel motility - Answer-C) rebound tenderness is a classic subjective sign of
appendicitis
Which client requires immediate nursing intervention? "The client who:
a) complains of epigastric pain after eating.
b) complains of anorexia and periumbilical pain.
c) presents with ribbonlike stools.
d) presents with a rigid, boardlike abdomen. - Answer-Correct: D
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.
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 - Answer-C.
Semi-fowlers aids in drainage and prevents spread of infection throughout the
abdominal cavity.
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:
a) administer Tylenol (acetaminophen) for the elevated temperature
b) advising the client to increase oral fluids
c) asking the client when she last had a bowel movement
d) notifying the physician - Answer-Correct D
D. The client symptoms indicate appendicitis which requires immediate attention
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-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.
Which of the nursing interventions should be implemented to manage appendicitis?
QUESTIONS AND ANSWERS
"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
3. Apply warmth to the abdomen with a heating pad
4. Use comfort measures and pillows to position the client" - Answer-Correct 4
"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 the 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"
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
A) urinary retention B) gastric hyperacidity C) rebound tenderness D) increased lower
bowel motility - Answer-C) rebound tenderness is a classic subjective sign of
appendicitis
Which client requires immediate nursing intervention? "The client who:
a) complains of epigastric pain after eating.
b) complains of anorexia and periumbilical pain.
c) presents with ribbonlike stools.
d) presents with a rigid, boardlike abdomen. - Answer-Correct: D
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.
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 - Answer-C.
Semi-fowlers aids in drainage and prevents spread of infection throughout the
abdominal cavity.
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:
a) administer Tylenol (acetaminophen) for the elevated temperature
b) advising the client to increase oral fluids
c) asking the client when she last had a bowel movement
d) notifying the physician - Answer-Correct D
D. The client symptoms indicate appendicitis which requires immediate attention
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-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.
Which of the nursing interventions should be implemented to manage appendicitis?
