The client has a possible diagnosis of appendicitis. On physical examination, the nurse should assess for tenderness on palpation at McBurney's point, located at which pictured site?

Answer and Explanation

The Correct Answer is B

McBurney's point is located approximately one-third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus (navel), on the right side of the abdomen.

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Correct Answer is A

Explanation

A. Teach the client to support the surgical site while deep breathing and coughing: This action is appropriate as it helps prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. Supporting the surgical site while deep breathing and coughing helps reduce pain and discomfort during these activities.
B. This is an important teaching point for clients using PCA for pain control after surgery. Opioid medications used in PCA can lead to gastrointestinal motility issues, including constipation. However, pain management is central within the first 24 hours post operation.
C. Irrigating and repositioning the NGT frequently can increase the risk of complications such as displacement or irritation of the surgical site. NGT care should be performed as needed based on institutional protocols and the client's condition.

D. The client's diet will likely be advanced gradually, starting with clear fluids and progressing to full liquids and then solid foods as tolerated. Fruit juices may be introduced gradually as part of the liquid diet once the client's gastrointestinal function has recovered sufficiently.

A. Pencil-thin stools B. Fecal-smelling breath C. Passage of mucus and blood in stools D. Absent bowel sounds and absent passage of flatus

Correct Answer is D

Explanation

D. In paralytic ileus, there is a lack of bowel motility, resulting in absent or diminished bowel sounds on auscultation and absent passage of flatus. The bowel sounds may be hypoactive or completely absent due to the lack of peristalsis. Additionally, the client may experience abdominal distention and discomfort due to the accumulation of gas and fluid in the intestines.
A. Pencil-thin stools are more commonly associated with conditions such as colorectal cancer or rectal strictures. In paralytic ileus, where there is a lack of bowel motility, the stools are typically absent rather than thin.
B. Fecal-smelling breath is not a typical finding in paralytic ileus. While it may occur in conditions associated with severe constipation or bowel obstruction, it is not specific to paralytic ileus.
C. Passage of mucus and blood in stools is not a characteristic finding of paralytic ileus. It is more commonly associated with conditions such as inflammatory bowel disease or colorectal cancer.

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The client has a possible diagnosis of appendicitis. On physical examination, the nurse should assess for tenderness on palpation at McBurney's point, located at which pictured site?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client diagnosed with a paralytic ileus. What would be an expected assessment finding?

Correct Answer is D

Explanation

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