exam 6 Ch. 58 Davis Appendicitis

Use of incentive spirometer Early ambulation as tolerated Assistance with turning, coughing, and deep breathing techniques (TCDB) CORRECT. To promote a prompt recovery, the client should be encouraged to use incentive spirometry to facilitate lung expansion. Similarly, assisting the client with TCDB techniques will facilitate lung expansion and prevent occurrence of postoperative atelectasis. Early ambulation is encouraged to prevent the occurrence of venous thromboembolism (VTE), which can be a complication of bed rest and immobility in the postoperative period.

In hopes of promoting a prompt recovery, which of the following aspects will be included in care planning for this client? Select all that apply. Use of incentive spirometer Early ambulation as tolerated Discontinuation of antibiotic therapy upon client becoming afebrile Assistance with turning, coughing, and deep breathing techniques (TCDB) Limiting oral fluids

Monitoring for return of bowel sounds before advancing diet

In managing postoperative care for a client who had an appendectomy, which nursing action would be included? Positioning the client on the right side for comfort Maintaining complete bed rest for the first 24 hours postoperatively Monitoring for return of bowel sounds before advancing diet Medicating the client for pain relief around the clock

A larger incision CORRECT. If the appendix has ruptured or peritonitis is expected, the surgeon will make a larger incision. Retention sutures may be indicated in obese clients or for complex wounds for which surgical edges cannot be approximated. Puncture wounds are used after a laparoscopic procedure and surgical wounds are not covered with an occlusive dressing.

The nurse is assessing the client's incision. Since the appendix was ruptured, what would the nurse expect to see? A larger incision Retention sutures in place Steri-strips over a small puncture wound Incision covered by an occlusive dressing

Do not allow the patient to eat or drink anything. Rationale: Surgery is likely and NPO is critical for safety. Administer an antipyretic. Rationale: This will bring the fever down but not correct the problem. Deliver pain medication as needed. Rationale: This is helpful but not a priority. Begin IV fluids. Rationale: Hydration is important, but the priority is informing the patient that they cannot have anything to eat or drink in case they go to surgery.

The nurse is caring for a patient with an elevated white blood cell count, fever, and rebound tenderness. What action is a priority? Do not allow the patient to eat or drink anything. Administer an antipyretic. Deliver pain medication as needed. Begin IV fluids.

Computed tomography scan

The nurse is caring for a patient with suspected appendicitis who has just arrived to the nursing unit. The nurse knows which test is most commonly used to diagnose appendicitis? Magnetic resonance imaging Computed tomography scan X-ray Ultrasound

"My antibiotics are used as needed." CORRECT. A client may have antibiotics prescribed, particularly if the appendix ruptured prior to surgery. The nurse should emphasize the importance of completing all antibiotics, even if having no symptoms. The other three statements are correct.

The nurse is performing discharge teaching with Andrew. Which statement by him requires additional teaching? "I will not drive after taking my pain medication." "If my wound opens up, I'll call the surgeon." "My antibiotics are used as needed." "I'll follow up with my surgeon in 7 days."

Place an ice pack to the right lower quadrant.

The nurse is taking care of a patient diagnosed with acute appendicitis who is awaiting surgical intervention. The patient is complaining of pain and has been medicated as ordered. What additional comfort measure would the nurse include in the plan of care to relieve the patient's pain? Place a warm compress on the area that the patient identifies as being the source of pain. Position for comfort on the right side with pillow support. Maintain patient's position in high fowler's to decrease pressure on the diaphragm. Place an ice pack to the right lower quadrant.

Pain at McBurney's point Rationale: As the inflammatory process progresses, pain is shifted to the right lower quadrant of the abdomen and becomes more severe and steady in the area of McBurney's point. Positive Rovsing's sign Rationale: Rovsing's sign, which presents when palpation of the left lower quadrant of the abdomen elicits pain in the right lower quadrant. Rebound tenderness Rationale: When the pain increases when pressure is released from McBurney's point. Normal findings Rationale: This is not a normal finding.

The patient comes to the emergency department with nausea, vomiting, and pain upon deep palpation in the middle of the RLQ. How should the nurse document this finding? Positive Rovsing's sign Pain at McBurney's point Rebound tenderness Normal findings

Supine with head of bed elevated 30° to 45° with knees flexed Rationale: This position decreases the strain (pull) on the abdominal muscles and may decrease pain secondary to inflammation in the peritoneal cavity. Head of bed flat with legs extended Rationale: This increases the strain on the abdominal muscles and will increase pain. Side lying with legs extended Rationale: Side lying can be comfortable but the knees should be bent for comfort. Prone with arms above the head Rationale: This position is not comfortable.

The patient with signs of appendicitis prefers not to take pain medication. What position may help to relieve the pain? Head of bed flat with legs extended Side lying with legs extended Supine with head of bed elevated 30° to 45° with knees flexed Prone with arms above the head

Its purpose is unknown Rationale: It is an accessory organ of the intestinal system but has no known function. Assists with fecal removal Rationale: This is not the function of the appendix. Assists with motility Rationale: Peristalsis assists with motility. Secretes digestive acid Rationale: The appendix is not a secreting organ.

What is the function of the appendix? Assists with fecal removal Assists with motility Its purpose is unknown Secretes digestive acid

Peritonitis Obstruction Abscess Gangrene Perforation

What potential complications can occur from untreated appendicitis? Select all that apply. Peritonitis Obstruction Abscess Gangrene Perforation

Abdominal tenderness Guarding in response to pain Right lower quadrant pain

Which assessment findings are consistent with identification of positive McBurney's point in a client with suspected appendicitis? Select all that apply. Abdominal tenderness Left lower quadrant pain Guarding in response to pain Right lower quadrant pain Hyperactive bowel sounds

Sudden pain resolution without medication or treatment Rationale: Changes in pain, particularly if abrupt, may indicate perforation. Development of a fever Rationale: A fever may not be present initially but will develop as inflammation increases. Elevated white blood cell (WBC) count Rationale: The patient with appendicitis will likely have an elevated WBC count with a left shift in the differential. Intense pain in the right lower quadrant Rationale: The patient with appendicitis experiences pain, particularly in the right lower quadrant.

Which assessment in the patient with appendicitis is most concerning? Development of a fever Elevated white blood cell (WBC) count Intense pain in the right lower quadrant Sudden pain resolution without medication or treatment

Changes in blood pressure and pulse

Which observation would indicate that the client's appendix had perforated? Changes in blood pressure and pulse Temperature 99.2°F 1+ pitting edema bilaterally lower legs Client experiences excessive thirst

Obtaining medical consult for therapeutic management of inflammation

Which order would the nurse question in a client who is admitted for appendicitis? Having the client sign the consent form for an appendectomy Maintaining NPO status prior to surgery Obtaining medical consult for therapeutic management of inflammation Monitoring vital signs

Development of abscess Peritonitis Gangrene

Which potential complications could arise if appendicitis is not diagnosed and treated promptly? Select all that apply. Development of abscess Viral infection Deep vein thrombosis Peritonitis Gangrene

20,000/mm3 Rationale: If the WBC is elevated to greater than 20,000/mm3, a perforated appendix should be suspected. 2,000/mm3 Rationale: This is neutropenia and not a sign of infection. 10,000/mm3 Rationale: The WBC may have a moderate increase with acute appendicitis (10,000-18,000/mm3). 18,000/mm3 Rationale: The WBC may have a moderate increase with acute appendicitis (10,000-18,000/mm3).

Which white blood cell (WBC) count indicates that perforation may have occurred from appendicitis? 2,000/mm3 10,000/mm3 18,000/mm3 20,000/mm3

A 16-year-old male Rationale: Affecting males more than females, appendicitis is a common condition that occurs highest in the 10- to 19-year-old age group. A 14-year-old female Rationale: It is more common in males in this age group. A 32-year-old male Rationale: It is more common in 10 to 19 year olds. A 42-year-old female Rationale: It is more common in younger males.

Who is at the highest risk of having appendicitis? A 16-year-old male A 14-year-old female A 32-year-old male A 42-year-old female

Position the patient with the right leg flexed Apply ice pack to the right lower quadrant CORRECT. Ice can be applied to the right lower quadrant to impede blood flow, helping to decrease inflammation. Positioning the client with the knees flexed will help relieve pressure. Heat is not used as it will increase blood flow to the area and increase inflammation. Pain medication should not be given prior to signing a surgical consent. NPO status should be maintained, but is not considered a comfort measure.

A 20-year-old male patient presents at the emergency room with recent onset acute abdominal pain in the right lower quadrant along with nausea, but no vomiting. He denies history of any comorbid conditions and does not take any prescription or over the counter medications. He is physically active and in overall good health apart from the symptoms he's experiencing. After the healthcare provider makes a clinical diagnosis of appendicitis, you prepare the patient for surgery. The patient is still complaining of pain prior to the surgery. Which interventions could be used to alleviate pain? Select all that apply: Apply warm compress to the right lower quadrant Position the patient with the right leg flexed Apply ice pack to the right lower quadrant Administer opioid analgesic prior to having the patient sign the surgical consent Maintain NPO status prior to surgery

The nurse places his or her hands on the right side of the abdomen.

A nurse is preparing to perform Rovsing's sign to determine if the client has appendicitis. Which action is incorrect? The nurse performs hand hygiene prior to the assessment. The nurse places his or her hands on the right side of the abdomen. The nurse provides an explanation of his or her action prior to touching the client. The nurse asks the client if he or she has any questions prior to touching the client.

Initiate intravenous access.

A patient has been diagnosed with acute appendicitis and is being prepped for surgery. Which order would the nurse question if noted in the physician's order? Initiate intravenous access. Maintain NPO status. Administer an enema. Withhold pain medication until the surgical consent is signed.

"Since your appendix has ruptured a larger incision will be make to irrigate out your abdominal cavity." Rationale: If the appendix is suspected of being ruptured and/or peritonitis is suspected, a laparotomy with a larger abdominal incision is made. "Most likely you will have an incision about an inch long." Rationale: There will be a larger incision for a ruptured appendix. "The procedure is often done laparoscopically, so there will be several small incisions." Rationale: This is the case if the appendix was not ruptured. "Typically, they cut from the base of the sternum to the pubic bone." Rationale: This would not be anticipated.

A patient is scheduled for surgery for a ruptured appendix and asks the nurse how large the incision will be. How should the nurse respond? "Most likely you will have an incision about an inch long." "The procedure is often done laparoscopically, so there will be several small incisions." "Since your appendix has ruptured a larger incision will be make to irrigate out your abdominal cavity." "Typically, they cut from the base of the sternum to the pubic bone."

Computed tomography (CT) Rationale: A CT scan is the most common diagnostic test to confirm appendicitis. X-ray of abdomen Rationale: X-rays of the abdomen will not help to confirm the diagnosis for appendicitis. Physical assessment Rationale: Physical assessment may reveal tenderness in the abdomen but will not confirm the diagnosis. White blood cell count Rationale: White blood cell counts may increase in appendicitis but alone do not confirm the diagnosis.

A patient reports abdominal pain, fever, and vomiting. The primary healthcare provider suspects appendicitis. Which diagnosis will confirm the condition? X-ray of abdomen Physical assessment White blood cell count Computed tomography (CT)

Presence of bowel sounds. CORRECT. Removal of the NG tube coincides with the return of bowel sounds in the postoperative period, as this indicates that peristalsis is returning. The other clinical findings support clinical improvement, but are not used as a determining factor for removal of a NG tube.

Andrew continues to recover from surgery and hopes that the NG tube will be removed soon. What clinical finding supports the removal of the NG tube? Client has resumed ambulation with minimal assistance. Less pain medication has been administered during a 12-hour shift. Client is able to tolerate small sips of liquids without nausea or vomiting. Presence of bowel sounds.

The consent must be signed before narcotics are administered. CORRECT. The nurse must ensure that the surgical consent form is signed prior to the client receiving any sedatives or narcotics. Legal age for consents is 18 years, not 21. Verbal consents are not acceptable for surgery. Although the surgeon should speak with the client before the consent is signed, the anesthesiologist typically does not.

Andrew is 20 and verbally consents to surgery. Which statement about the consent is true? Andrew's parents must be contacted since he is younger than 21. The consent must be signed before narcotics are administered. A verbal consent is acceptable and the nurse can document that. The consent cannot be signed until the anesthesiologist sees Andrew.

Gangrene can occur and is life-threatening. Abscess can happen if the bacterial invasion is slow. Rupture can occur in as little as 24 hours, which results in peritonitis. CORRECT. Without treatment for appendicitis, bacterial invasion occurs and an abscess may develop. Gangrene can occur in as little as 24 to 36 hours and is life-threatening. Perforation can occur in as little as 24 hours, but the risk increases after 48 hours and can result in peritonitis, which can also be fatal.

Andrew is frightened to have surgery. He asks the nurse why surgery is needed, saying, "What's the worst thing that could happen if I just leave it alone?" What complications should the nurse include in the teaching discussion? Select all that apply. It will heal over time. Gangrene can occur and is life-threatening. Abscess can happen if the bacterial invasion is slow. The pain becomes excruciating. Rupture can occur in as little as 24 hours, which results in peritonitis.

Monitoring nasogastric (NG) tube attached to low intermittent suction for drainage CORRECT. Since the appendix has ruptured, the client is at high risk for infection and aspiration of matter released into circulation in the abdominal area. An NG tube hooked up to low intermittent suction will be required in the immediate postoperative period. NPO status is typically maintained until bowel sounds return and the NG tube is withdrawn. TPN is not required as a postoperative nutrition management method as a quick recovery time is anticipated even with the complication of rupture.

Andrew's appendectomy is performed, revealing that the appendix has ruptured. Based on this finding, what should the nurse include in the postoperative care? Providing nourishment by administering total parenteral nutrition (TPN) in the postoperative period Advancing diet as tolerated within 24 hours of surgery Monitoring nasogastric (NG) tube attached to low intermittent suction for drainage Maintaining complete bedrest with both side rails up to ensure safety