A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
Left upper quadrant
Right upper quadrant
Right lower quadrant
Left upper quadrant
The Correct Answer is C
Choice A reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice B reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice C reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice D reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
Chronic gastritis is not a common immediate postoperative complication of gastric surgery. It is more related to long-term gastric health.
Choice B reason:
Correct. Atelectasis, or partial lung collapse, is a potential complication postoperatively, especially in abdominal surgery. The nurse should assess for signs such as decreased breath sounds and reduced oxygen saturation.
Choice C reason:
Correct. Pneumonia is a potential complication due to reduced lung function and shallow breathing after surgery. The nurse should monitor for signs like fever, increased respiratory rate, and abnormal breath sounds.
Choice D reason:
Malignant hyperthermia is a rare complication related to certain types of anesthesia agents. It is not a common complication after gastric surgery.
Choice E reason:
Correct. Metabolic imbalances, such as electrolyte disturbances or changes in blood glucose levels, can occur after gastric surgery. The nurse should monitor for signs like weakness, confusion, and abnormal laboratory values.
Correct Answer is C
Explanation
Choice A reason:
This statement does not address the client's use of bisacodyl tablets and instead provides general information about irregular bowel movements.
Choice B reason:
Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.
Choice C reason:
This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially disrupt electrolyte levels.
Choice D reason:
While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.
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