Gastro Nclex Questions

Which of the following complications is thought to be the most common cause of appendicitis?
A. A fecalith
B. Bowel kinking
C. Internal bowel occlusion
D. Abdominal bowel swelling

A. 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

Which of the following terms best describes the pain associated with appendicitis?
A. Aching
B. Fleeting
C. Intermittent
D. Steady

D. The pain begins in the epigastrium or periumbilical region, then shifts to the right lower quadrant and becomes steady. The pain may be moderate to severe.

Which of the following nursing interventions should be implemented to manage a client with appendicitis?
A. Assessing for pain
B. Encouraging oral intake of clear fluids
C. Providing discharge teaching
D. Assessing for symptoms of peritonitis

D. The focus of care is to assess for peritonitis, or inflammation of the peritoneal cavity. Peritonitis is most commonly caused by appendix rupture and invasion of bacteria, which could be lethal. The client with appendicitis will have pain that should b

Which of the following definitions best describes gastritis?
A. Erosion of the gastric mucosa
B. Inflammation of a diverticulum
C. Inflammation of the gastric mucosa
D. Reflux of stomach acid into the esophagus

C. Gastritis is an inflammation of the gastric mucosa that may be acute (often resulting from exposure to local irritants) or chronic (associated with autoimmune infections or atrophic disorders of the stomach). Erosion of the mucosa results in ulceration

Which of the following substances is most likely to cause gastritis?
A. Milk
B. Bicarbonate of soda, or baking soda
C. Enteric coated aspirin
D. Nonsteriodal anti-imflammatory drugs

D. NSAIDS are a common cause of gastritis because they inhibit prostaglandin synthesis. Milk, once thought to help gastritis, has little effect on the stomach mucosa. Bicarbonate of soda, or baking soda, may be used to neutralize stomach acid, but it shou

Which of the following definitions best describes diverticulosis?
A. An inflamed outpouching of the intestine
B. A noninflamed outpouching of the intestine
C. The partial impairment of the forward flow of intestinal contents
D. An abnormal protrusion of a

B. Diverticulosis involves a noninflamed outpouching of the intestine. Diverticulitis involves an inflamed outpouching. The partial impairment of forward flow of the intestine is an obstruction; abnormal protrusion of an organ is a hernia.

Which of the following types of diets is implicated in the development of diverticulosis?
A. Low-fiber diet
B. High-fiber diet
C. High-protein diet
D. Low-carbohydrate diet

A. Low-fiber diets have been implicated in the development of diverticula because these diets decrease the bulk in the stool and predispose the person to the development of constipation. A high-fiber diet is recommended to help prevent diverticulosis. A h

Which of the following mechanisms can facilitate the development of diverticulosis into diverticulitis?
A. Treating constipation with chronic laxative use, leading to dependence on laxatives
B. Chronic constipation causing an obstruction, reducing forward

D. Undigested food can block the diverticulum, decreasing blood supply to the area and predisposing the area to invasion of bacteria. Chronic laxative use is a common problem in elderly clients, but it doesn't cause diverticulitis. Chronic constipation ca

Which of the following symptoms indicated diverticulosis?
A. No symptoms exist
B. Change in bowel habits
C. Anorexia with low-grade fever
D. Episodic, dull, or steady midabdominal pain

A. Diverticulosis is an asymptomatic condition. The other choices are signs and symptoms of diverticulitis.

Which of the following tests should be administered to a client suspected of having diverticulosis?
A. Abdominal ultrasound
B. Barium enema
C. Barium swallow
D. Gastroscopy

B. A barium enema will cause diverticula to fill with barium and be easily seen on x-ray. An abdominal US can tell more about structures, such as the gallbladder, liver, and spleen, than the intestine. A barium swallow and gastroscopy view upper GI struct

Medical management of the client with diverticulitis should include which of the following treatments?
A. Reduced fluid intake
B. Increased fiber in diet
C. Administration of antibiotics
D. Exercises to increase intra-abdominal pressur

C. Antibiotics are used to reduce the inflammation. The client isn't typically isn't allowed anything orally until the acute episode subsides. Parenteral fluids are given until the client feels better; then it's recommended that the client drink eight 8-o

Crohn's disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease?
A. The entire length of the large colon
B. Only the sigmoid area
C. The entire large colon through the layers

D. Crohn's disease can involve any segment of the small intestine, the colon, or both, affecting the entire thickness of the bowel. Answers 1 and 3 describe ulcerative colitis, answer 2 is too specific and therefore, not likely.

Which area of the alimentary canal is the most common location for Crohn's disease?
A. Ascending colon
B. Descending colon
C. Sigmoid colon
D. Terminal ileum

D. Studies have shown that the terminal ileum is the most common site for recurrence in clients with Crohn's disease. The other areas may be involved but aren't as common.

Which of the following factors is believed to be linked to Crohn's disease?
A. Constipation
B. Diet
C. Hereditary
D. Lack of exercise

C. Although the definite cause of Crohn's disease is unknown, it's thought to be associated with infectious, immune, or psychological factors. Because it has a higher incidence in siblings, it may have a genetic cause.

15. Which of the following factors is believed to cause ulcerative colitis?
A. Acidic diet
B. Altered immunity
C. Chronic constipation
D. Emotional stress

B. Several theories exist regarding the cause of ulcerative colitis. One suggests altered immunity as the cause based on the extraintestinal characteristics of the disease, such as peripheral arthritis and cholangitis. Diet and constipation have no effect

Fistulas are most common with which of the following bowel disorders?
A. Crohn's disease
B. Diverticulitis
C. Diverticulosis
D. Ulcerative colitis

A. The lesions of Crohn's disease are transmural; that is, they involve all thickness of the bowel. These lesions may perforate the bowel wall, forming fistulas with adjacent structures. Fistulas don't develop in diverticulitis or diverticulosis. The ulce

Which of the following areas is the most common site of fistulas in client's with Crohn's disease?
A. Anorectal
B. Ileum
C. Rectovaginal
D. Transverse colon

A. Fistulas occur in all these areas, but the anorectal area is most common because of the relative thinness of the intestinal wall in this area.

Which of the following associated disorders may a client with ulcerative colitis exhibit?
A. Gallstones
B. Hydronephrosis
C. Nephrolithiasis
D. Toxic megacolon

D. Toxic megacolon is extreme dilation of a segment of the diseased colon caused by paralysis of the colon, resulting in complete obstruction. This disorder is associated with both Crohn's disease and ulcerative colitis. The other disorders are more commo

Which of the following associated disorders may the client with Crohn's disease exhibit?
A. Ankylosing spondylitis
B. Colon cancer
C. Malabsorption
D. Lactase deficiency

C. Because of the transmural nature of Crohn's disease lesions, malaborption may occur with Crohn's disease. Ankylosing spondylitis and colon cancer are more commonly associated with ulcerative colitis. Lactase deficiency is caused by a congenital defect

Which of the following symptoms may be exhibited by a client with Crohn's disease?
A. Bloody diarrhea
B. Narrow stools
C. N/V
D. Steatorrhea

D. Steatorrhea from malaborption can occur with Crohn's disease. N/V, and bloody diarrhea are symptoms of ulcerative colitis. Narrow stools are associated with diverticular disease.

Which of the following symptoms is associated with ulcerative colitis?
A. Dumping syndrome
B. Rectal bleeding
C. Soft stools
D. Fistulas

B. In ulcerative colitis, rectal bleeding is the predominant symptom. Soft stools are more commonly associated with Crohn's disease, in which malabsorption is more of a problem. Dumping syndrome occurs after gastric surgeries. Fistulas are associated with

If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn's disease or ulcerative colitis?
A. Abdominal computed tomography (CT) scan
B. Abdominal x-ray
C. Barium swallow
D. Colonoscopy wit

D. A colonoscopy with biopsy can be performed to determine the state of the colon's mucosal layers, presence of ulcerations, and level of cytologic development. An abdominal x-ray or CT scan wouldn't provide the cytologic information necessary to diagnose

Which of the following interventions should be included in the medical management of Crohn's disease?
A. Increasing oral intake of fiber
B. Administering laxatives
C. Using long-term steroid therapy
D. Increasing physical activity

C. Management of Crohn's disease may include long-term steroid therapy to reduce the inflammation associated with the deeper layers of the bowel wall. Other management focuses on bowel rest (not increasing oral intake) and reducing diarrhea with medicatio

In a client with Crohn's disease, which of the following symptoms should not be a direct result from antibiotic therapy?
A. Decrease in bleeding
B. Decrease in temperature
C. Decrease in body weight
D. Decrease in the number of stools

C. A decrease in body weight may occur during therapy due to inadequate dietary intake, but isn't related to antibiotic therapy. Effective antibiotic therapy will be noted by a decrease in temperature, number of stools, and bleeding.

Surgical management of ulcerative colitis may be performed to treat which of the following complications?
A. Gastritis
B. Bowel herniation
C. Bowel outpouching
D. Bowel perforation

D. Perforation, obstruction, hemorrhage, and toxic megacolon are common complications of ulcerative colitis that may require surgery. Herniation and gastritis aren't associated with irritable bowel diseases, and outpouching of the bowel is diverticulosis.

Which of the following medications is most effective for treating the pain associated with irritable bowel disease?
A. Acetaminophen
B. Opiates
C. Steroids
D. Stool softeners

C. The pain with irritable bowel disease is caused by inflammation, which steroids can reduce. Stool softeners aren't necessary. Acetaminophen has little effect on the pain, and opiate narcotics won't treat its underlying cause (I feel this is untrue�dila

During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care?
A. Body image
B. Ostomy care
C. Sexual concerns
D. Skin care

B. Although all of these are concerns the nurse should address, being able to safely manage the ostomy is crucial for the client before discharge.

Colon cancer is most closely associated with which of the following conditions?
A. Appendicitis
B. Hemorrhoids
C. Hiatal hernia
D. Ulcerative colitis

D. Chronic ulcerative colitis, granulomas, and familial polposis seem to increase a person's chance of developing colon cancer. The other conditions listed have no known effect on colon cancer risk.

Which of the following diets is most commonly associated with colon cancer?
A. Low-fiber, high fat
B. Low-fat, high-fiber
C. Low-protein, high-carbohydrate
D. Low carbohydrate, high protein

A. A low-fiber, high-fat diet reduced motility and increases the chance of constipation. The metabolic end products of this type of diet are carcinogenic. A low-fat, high-fiber diet is recommended to prevent colon cancer.

Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer?
A. Abdominal CT scan
B. Abdominal x-ray
C. Colonoscopy
D. Fecal occult blood test

D. Surface blood vessels of polyps and cancers are fragile and often bleed with the passage of stools. Abdominal x-ray and CT scan can help establish tumor size and metastasis. A colonoscopy can help locate a tumor as well as polyps, which can be removed

Radiation therapy is used to treat colon cancer before surgery for which of the following reasons?
A. Reducing the size of the tumor
B. Eliminating the malignant cells
C. Curing the cancer
D. Helping the bowel heal after surgery

A. Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor, making it easier to be resected. Radiation therapy isn't curative, can't eliminate the malignant cells (though it helps define tumor margins), can could slo

Which of the following symptoms is a client with colon cancer most likely to exhibit?
A. A change in appetite
B. A change in bowel habits
C. An increase in body weight
D. An increase in body temperature

B. The most common complaint of the client with colon cancer is a change in bowel habits. The client may have anorexia, secondary abdominal distention, or weight loss. Fever isn't associated with colon cancer.

A client has just had surgery for colon cancer. Which of the following disorders might the client develop?
A. Peritonitis
B. Diverticulosis
C. Partial bowel obstruction
D. Complete bowel obstruction

A. Bowel spillage could occur during surgery, resulting in peritonitis. Complete or partial bowel obstruction may occur before bowel resection. Diverticulosis doesn't result from surgery or colon cancer.

A client with gastric cancer may exhibit which of the following symptoms?
A. Abdominal cramping
B. Constant hunger
C. Feeling of fullness
D. Weight gain

C. The client with gastric cancer may report a feeling of fullness in the stomach, but not enough to cause him to seek medical attention. Abdominal cramping isn't associated with gastric cancer. Anorexia and weight loss (not increased hunger or weight gai

Which of the following diagnostic tests may be performed to determine if a client has gastric cancer?
A. Barium enema
B. Colonoscopy
C. Gastroscopy
D. Serum chemistry levels

C. A gastroscopy will allow direct visualization of the tumor. A colonoscopy or a barium enema would help diagnose colon cancer. Serum chemistry levels don't contribute data useful to the assessment of gastric cancer.

A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer?
A. Discharge planning
B. Correction of nutritional deficits
C. Prevent

B. Client's with gastric cancer commonly have nutritional deficits and may be cachectic. Discharge planning before surgery is important, but correcting the nutrition deficit is a higher priority. At present, radiation therapy hasn't been proven effective

Care for the postoperative client after gastric resection should focus on which of the following problems?
A. Body image
B. Nutritional needs
C. Skin care
D. Spiritual needs

B. After gastric resection, a client may require total parenteral nutrition or jejunostomy tube feedings to maintain adequate nutritional status.

Which of the following complications of gastric resection should the nurse teach the client to watch for?
A. Constipation
B. Dumping syndrome
C. Gastric spasm
D. Intestinal spasms

B. Dumping syndrome is a problem that occurs postprandially after gastric resection because ingested food rapidly enters the jejunum without proper mixing and without the normal duodenal digestive processing. Diarrhea, not constipation, may also be a symp

A client with rectal cancer may exhibit which of the following symptoms?
A. Abdominal fullness
B. Gastric fullness
C. Rectal bleeding
D. Right upper quadrant pain

C. Rectal bleeding is a common symptom of rectal cancer. Rectal cancer may be missed because other conditions such as hemorrhoids can cause rectal bleeding. Abdominal fullness may occur with colon cancer, gastric fullness may occur with gastric cancer, an

A client with which of the following conditions may be likely to develop rectal cancer?
A. Adenomatous polyps
B. Diverticulitis
C. Hemorrhoids
D. Peptic ulcer disease

A. A client with adenomatous polyps has a higher risk for developing rectal cancer than others do. Clients with diverticulitis are more likely to develop colon cancer. Hemorrhoids don't increase the chance of any type of cancer. Clients with peptic ulcer

Which of the following treatments is used for rectal cancer but not for colon cancer?
A. Chemotherapy
B. Colonoscopy
C. Radiation
D. Surgical resection

C. A client with rectal cancer can expect to have radiation therapy in addition to chemotherapy and surgical resection of the tumor. A colonoscopy is performed to diagnose the disease. Radiation therapy isn't usually indicated in colon cancer.

Which of the following conditions is most likely to directly cause peritonitis?
A. Cholelithiasis
B. Gastritis
C. Perforated ulcer
D. Incarcerated hernia

C. The most common cause of peritonitis is a perforated ulcer, which can pour contaminates into the peritoneal cavity, causing inflammation and infection within the cavity. The other conditions don't by themselves cause peritonitis. However, if cholelithi

Which of the following symptoms would a client in the early stages of peritonitis exhibit?
A. Abdominal distention
B. Abdominal pain and rigidity
C. Hyperactive bowel sounds
D. Right upper quadrant pain

B. Abdominal pain causing rigidity of the abdominal muscles is characteristic of peritonitis. Abdominal distention may occur as a late sign but not early on. Bowel sounds may be normal or decreased but not increased. Right upper quadrant pain is chatacter

Which of the following laboratory results would be expected in a client with peritonitis?
A. Partial thromboplastin time above 100 seconds
B. Hemoglobin level below 10 mg/dL
C. Potassium level above 5.5 mEq/L
D. White blood cell count above 15,000

D. Because of infection, the client's WBC count will be elevated. A hemoglobin level below 10 mg/dl may occur from hemorrhage. A PT time longer than 100 seconds may suggest disseminated intravascular coagulation, a serious complication of septic shock. A

Which of the following therapies is not included in the medical management of a client with peritonitis?
A. Broad-spectrum antibiotics
B. Electrolyte replacement
C. I.V. fluids
D. Regular diet

D. The client with peritonitis usually isn't allowed anything orally until the source of peritonitis is confirmed and treated. The client also requires broad-spectrum antibiotics to combat the infection. I.V. fluids are given to maintain hydration and hem

Which of the following aspects is the priority focus of nursing management for a client with peritonitis?
A. Fluid and electrolyte balance
B. Gastric irrigation
C. Pain management
D. Psychosocial issues

A. Peritonitis can advance to shock and circulatory failure, so fluid and electrolyte balance is the priority focus of nursing management. Gastric irrigation may be needed periodically to ensure patency of the nasogastric tube. Although pain management is

A client with irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should the nurse give the client?
A. Low fiber, low-fat
B. High fiber, low-fat
C. Low fiber, high-fat
D. High-fiber, high-fat

B. The client with irritable bowel syndrome needs to be on a diet that contains at least 25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms.

A client presents to the emergency room, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts him at risk for which of the following?
A. Metabolic acidosis with hyperkalemia
B. Metabolic acidosis with hyp

D. Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive loss of these substances, such as from vomiting, can lead to metabolic alkalosis and hypokalemia.

Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?
A. Imbalanced nutrition: Less than body requirements
B. Acute pain
C. Defici

C. Fluid shifts to the site of the bowel obstruction, causing a fluid deficit in the intravascular spaces. If the obstruction isn't resolved immediately, the client may experience an imbalanced nutritional status (less than body requirements); however, de

When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include?
A. "Drink 6 glasses of fluid each day."
B. "Avoid grain products and nuts."
C. "Add at least 4 grams of brain to your cereal each mo

D. Exercise helps prevent constipation. Fluids and dietary fiber promote normal bowel function. The client should drink eight to ten glasses of fluid each day. Although adding bran to cereal helps prevent constipation by increasing dietary fiber, the clie

In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?
A. The client passes formed stools at regular intervals
B. The client reports a decrease in stool frequency and liquidity
C. The client exhibits firm skin turgor
D.

C. A client with diarrhea has a nursing diagnosis of Deficient fluid volume related to excessive fluid loss in the stool. Expected outcomes include firm skin turgor, moist mucous membranes, and urine output of at least 30 ml/hr. The client also has a nurs

When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include?
A. "Limit fat intake to 20% to 25% of your total daily calories."
B. "Include 15 to 20 grams of fiber into your daily diet."
C. "Get an ann

A. To help prevent colon cancer, fats should account for no more than 20% to 25% of total daily calories and the diet should include 25 to 30 grams of fiber per day. A digital rectal examination isn't recommended as a stand-alone test for colorectal cance

A 30-year old client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after birth of her 2nd child. Diagnostic tests reveal gluten-induced enteropathy. Which foods must she eliminate from her diet permanently

C. To manage gluten-induced enteropathy, the client must eliminate gluten, which means avoiding all cereal grains except for rice and corn. In initial disease management, clients eat a high calorie, high-protein diet with mineral and vitamin supplements t

After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate?
A. Asking a co-worker to help turn the client
B. Explaining to the client why turning i

B. The appropriate action is to explain the importance of turning to avoid postoperative complications. Asking a coworker to help turn the client would infringe on his rights. Allowing him to turn when he's ready would increase his risk for postoperative

A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?
A. Semi-Fowlers
B. Supine
C. Reverse Trendelenburg
D. High Fowler's

A. To prevent aspiration of stomach contents, the nurse should place the client in semi-Fowler's position. High Fowler's position isn't necessary and may not be tolerated as well as semi-Fowler's.

An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?
A. Prepare 750 ml of irrigating solution warmed to 100*F
B. Question the physician about the order
C. Provide privacy and explain the pr

B. Enemas are contraindicated in an acute abdominal condition of unknown origin as well as after recent colon or rectal surgery or myocardial infarction. The other answers are correct only when enema administration is appropriate.

The client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?
A. Fast for 8 hours before the test
B. Eat a regul

A. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the GI tract. The client should fast for 8 to 12 hours before the test, depending on the physician instructions. Most oral medications als

The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?
A. Abdominal cramping and pain
B. Bradycardia and indigestion
C. Sweating and pallor
D. Double vision and chest pain

C. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?
A. Restricting pain medication
B. Maintaining bedrest
C. Avoiding coughing
D. Irrigating the dr

C. Bedrest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?
A. Bloody diarrhea
B. Hypotension
C. A hemoglobin of 12 mg/dL
D. Rebound te

D. Rebound tenderness may indicate peritonitis. Blood diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to

The nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to note documented on the client's record?
A. Chronic constipation
B. Diarrhea
C. Constipation alternating with diarrhe

B. Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration and severity. The other option are not associated with diarrhea.

The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?
A. Notify the physician
B. Increase the height of the irriga

C. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigati

The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?
A. Increase fluid intake
B. Reduce the amount of irrigation

A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and prevent constipation.

The nurse is reviewing the physician's orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client's chart?
A. NPO status
B. Insert a nasogastric tube
C. An anticholinergic medication

D. Meperidine (Demerol) rather than morphine is the medication of choice because morphine can cause spasm in the sphincter of Oddi.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which of the following most frequent symptom(s) of duodenal ulcer?
A. Pain

A. The most frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usu

The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma?
A. Cleanse the peristomal skin meticulously
B. Take in high-fiber foods such as nuts
C. Massage the area below the stoma
D. Limit fluid intake

A. The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be

The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:
A. Watches the nurse empty the co

D. The client is expected to have a body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest deal of acceptance when the client participates in the actual c

The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?
A. Sunken and hidden stoma
B. Dark- and bluish-colored stoma
C. Narrowed and flattened stoma
D. Protruding s

D. A prolapsed stoma is one which the bowel protruded through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening at the level of the

The client with a new colostomy is concerned about the odor from the stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
A. Yogurt
B. Broccoli
C. Cucumbers
D. Eggs

A. The client should be taught to include deodorizing foods in the diet, such a beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas forming food as well. Broccoli, cucumbers, and eggs are gas forming foods.

The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less wate

C. Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase output of watery stool by increasing propulsion through the bowel. Ileostomy output i

The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?
A. Intestinal obstruction
B. Fluid and electrolyte imbala

B. A major complication that occurs most frequent following an ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from happening. Losses require replacement by intravenous infusion un

The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?
A. "I

A. A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about 3 times a day or as needed when full. The client does not need to wear a drainage bag but shoul

The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?
A. Distilled water
B. Tap water
C. Sterile water
D. Lactated Ringer's

B. Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, then bottled water should be used.

A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client 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

B. Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client w

The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:
A. Severe and unrelenting, located in the epigastric area and radiating to the back.
B. Severe and unrelenting, located in the left l

A. The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.

The client with Crohn's disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?
A. Lying supine with the legs straight
B. Massaging the abdomen
C. Using antispasmodic medica

A. The pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also is reduced by having the client practice relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying wit

A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication:
A. 30 minutes before meals
B. On an empty stomach
C. After meals
D. On arising

C. Salicylate compounds act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. This medication needs to be taken

During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of a NG tube. Based on these findings, the

D. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis, or inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combin

The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
A. The stoma is slightly edematous
B. The stoma is dark red to purple
C. The stoma oozes a small

B. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early post-op period. The colostomy would typically not begin functioning until 2-4 days after surgery.

When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.
A. Assessing the client's bowel sounds
B. Providing s

B, D, E and 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel so

Which goal of the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?
A. Promoting self-care and independence
B. Managing diarrhea
C. Maintaining adequate nutrition
D. Promoting rest and c

B. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive a

A client's ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?
A. Heart failure
B. DVT
C. Hypokalemia
D. Hypocalcemia

C. Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failu

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help

C. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into 6 small meals does not allow

The nurse would increase the comfort of the patient with appendicitis by:
a. Having the patient lie prone
b. Flexing the patient's right knee
c. Sitting the patient upright in a chair
d. Turning the patient onto his or her left side

Correct answer: B"
The patient with appendicitis usually prefers to lie still, often with the right leg flexed to decrease pain.

The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the patient complains of pain in the right lower quadrant. T

Answer A
In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.

Which of the following position should the client with appendicitis assume to relieve pain ?
A. Prone
B. Sitting
C. Supine
D. Lying with legs drawn up

Correct Answer: D Lying still with legs drawn up towards chest helps relive tension on the abdominal muscle, which helps to reduce the amount of discomfort felt. Lying flat or sitting may increase the amount of pain experienced

When evaluating a male client for complications of acute pancreatitis, the nurse would observe for:
"a. increased intracranial pressure.
b. decreased urine output.
c. bradycardia.
d. hypertension.

Correct Answer: B
Rationale: Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycar

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. Obst

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

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

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 pressu

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 soun

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. Scheduli

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 swelli

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 occlus

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. Obst

Correct 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

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 obstruc

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 c

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. Obstr

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 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 abdo

Correct 1
Based on the signs and symptoms presented in the question, the nurse shoudl suspect peritonitis and notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client w

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. Obstru

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 client diagnosed with appendicitis has undergone an appendectomy. At two hours postoperative, the nurse takes the vital signs and notes T 102.6 F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority.
1

Order of priority: 1, 3, 4, 5, 2."
"1. The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained.
3. The foot of the bed should be elevated to help treat shock, the symptoms of which include ele

A client is admitted with right lower quadrant pain, anorexia, nausea, low-grade fever, and an elevated white blood cell count. Which complication is most likely the cause?
"1. A fecalith
2. Bowel kinking
3. Internal bowel occlusion
4. Abdominal wall swe

Correct 1
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 in

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 s

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 p

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. Obstr

Correct 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

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 quadr

Correct 4
"1. ""Encourage the client..."" - unnecesary movement will increase pain and should be avoided
2. ""Massage the lower..."" - if appendicitis is suspected, massorge or palpation should never be performed as thes actions may cause the appendix to

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. Obst

Correct: B - no rationale

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

Correct: 4 - no rationale

A nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client does have appendicitis?
1. Leukopenia with a shift to the rig

Answer 2 - no rationale

The nurse is monitoring a client admitted to the hospital with a dx 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

Answer A
The health-care provider should be noti-?ed when the nurse has the needed infor-mation.`

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 hyp

C) rebound tenderness is a classic subjective sign of appendicitis

The health care team is assessing a patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis?
A. Gastric pH
B. Blood glucose
C.

Correct: C
Serum amylase levels indicate pancreatic function, and they are used to diagnose acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.

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.

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 appendici

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. The nurse should:
"1. Contact the surgeon to req

Correct: 3 - no rationale

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for:
a) colonoscopy.
b) surgery.
c) nasogastric (NG) tube insertion.
d) barium enema.

B) Surgery
The client should be prepared for surgery because his signs and symptoms indicate bowel perforation. Appendicitis is the most common cause of bowel perforation in the United States. Because perforation can lead to peritonitis and sepsis, surge

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. Semi-fowlers aids in drainage and prevents spread of infection throughout the abodominal 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 b

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

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 inofor

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 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

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 pota

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

The doctor ordered for a complete blood count. After the
test, Nurse Ray received the result from the laboratory. Which
laboratory values will confirm the diagnosis of appendicitis?
a. RBC 5.5 x 106/mm3
b. Hct 44 %
c. WBC 13, 000/mm3
d. Hgb 15 g/dL

Answer C
"Rationale: Increase in WBC counts is suggestive of appendicitis because
of bacterial invasion and inflammation. Normal WBC count is 5, 000 - 10,
000/mm3. Other options are normal values.

A client has an appendectomy. This is an example of what kind of surgery? a. Diagnostic b. palliative c. ablative d. constructive

Correct: C
Appendectomy is an example of ablative surgery. Diagnostic confirms or establishes a diagnosis, palliative relieves or reduces pain, and constructive restores function or appearance.

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: 4
Rationale: A tense, rigid abdomen is an early symptom of peritonitis. The other findings are expected in the immediate postoperative period.

A client has an appendectomy and develops peritonitis. The nurse should asses the client for an elevated temperature and which additional clinical indication commonly associated with peritonitis?
"1. hyperactivity
2. extreme hunger
3. urinary retention
4

Correct: 4
muscular rigidity over the affected area is a classic sign of peritonitis

A nurse is caring for a child who had a laproscopic appendectomy. What interventions should the nurse document on the child's clinical record? Select all that apply.
1) Intake and Output 2) Measurement of Pain 3) Tolerance to low-residue diet 4) Frequency

Answer: 1, 2, 5
1) Assessment and documentation of fluid balance are critical aspects of all postoperative care. 2) Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is absorbed. The amount of pain should

The nurse is assessing an adolescent who is admitted to the hospital with appendicitis. The nurse should report which of the following to the HCP?
"1) change in pain rating of 7 to 8 on a 10 point scale.
2) sudden relief of sharp pain, shifting to diffuse

Answer: 2
Rationale: The nurse notifies the HCP if the client has sudden relief of sharp pain and on presence of more diffuse pain. this change in the pain indicates the appendix has ruprured. The diffuse pain is typically accompanied by rigid guarding of

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) m

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 cha

During the assessment of a patient with acute abdominal pain, the nurse should:
a. Perform deep palpation before ascultation
b. Obtain blood pressure and pulse rate to determine hypervolemic changes
c. Ascultate bowel sounds because hyperactive bowel sou

Correct answer: d
Rationale: For the patient complaining of acute abdominal pain, the nurse should take vital signs immediately. Increased pulse and decreasing blood pressure (BP) are indicative of hypovolemia. An elevated temperature suggests an inflamm

A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?
1. Remove the dressing and leave

Correct 4
The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the

which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
1. "i will take my temp each week and report any elevation." 2. "i will not need any pain meds when i go home." 3. i will take a

Correct 3
1. the client should check the temp twice a day. 2. it is not realistic to expect the client to experience no pain after surgery. 3 (CORRECT): this statement about taking all the antibiotics ordered indicates the teaching is effective. 4. client

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. The nurse should:
"1. Contact the surgeon to requ

Correct: 3
The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not order narcotic medication prior to surgery. The nurse can

Which of the following would confirm a diagnosis of appendicitis?
"a. The pain is localized at a position halfway between the umbilicus and the right iliac crest.
b. Mr. Liu describes the pain as occurring 2 hours after eating
c. The pain subsides after e

Correct A
"Pain over McBurney's point, the point halfway between the umbilicus and
the iliac crest, is diagnosis for appendicitis. Options b and c are
common with ulcers; option d may suggest ulcerative

Which of the following would indicate that Bobby's appendix has ruptured? "
a) diaphoresis
b) anorexia
c) pain at Mc Burney's point
d) relief from pain

Correct D
all are normal signs of having appendicits and once you have relief from pain means you could have a rupture.

Which of the following complications is thought to be the most common cause of appendicitis?
a. A fecalith
b. Internal bowel occlusion
c. Bowel kinking
d. Abdominal wall swelling

Answer: A. A fecalith
Rationale: A fecalith is a hard piece of stool which is stone like that commonly obstructs the lumen. Due to obstruction, inflammation and bacterial invasion can occur. Tumors or foreign bodies may also cause obstruction.

The client with sever abdominal pain is being evaluated for appendicitis. What is the most common cause of appendicistis? http://nursing.slcc.edu/nclexrn3500/ 1. Rupture of the appendix
2.Obstruction of the appendix
3 A high-fat diet
4. A duodenal ulcer

Correct 2
Appendicitis most commonly results from obstruction of the appendix, which may lead to rupture. A high-fat diet or duodenal ulcer doesn't cause appendicitis; however, a client may require dietary restrictions after an appendectomy

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 obstruct

Answer 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

The nurse is caring for the following clients on a surgical unit. Which client would the nurse assess ?rst?
1.The client who had an inguinal hernia repair and has not voided in four (4) hours.
2.The client who was admitted with abdominal pain who suddenly

Correct: 2
"1. A client who has not voided within four (4)hours after any surgery would not be priority. This is an acceptable occurrence, but if the client hasn't voided for eight (8) hours, then the nurse would assess further.
2.This could indicate a ru

The nurse is caring for a patient following an appendectomy. The patient
takes a deep breath, coughs, and then winces in pain. Which of the
following statements, if made by the nurse to the patient, is BEST?
"A.) "Take three deep breaths, hold your incis

(1) correct-most effective way of deep breathing and coughing, dilates airway and
expands lung surface area
(2) should splint incision before coughing to reduce discomfort and increase
efficiency
(3) partial answer, should take three deep breaths before