The nurse is assessing a client with suspected appendicitis. Which finding is most indicative of this condition?

Rebound tenderness in the right lower quadrant

Diffuse abdominal pain

Decreased bowel sounds

Elevated blood pressure

Answer and Explanation

The Correct Answer is A

Choice A reason: Rebound tenderness in the right lower quadrant (McBurney’s point) is a hallmark of appendicitis, indicating peritoneal irritation from an inflamed appendix. This localized pain, elicited on palpation release, is highly specific, guiding urgent surgical evaluation to prevent rupture and peritonitis.

Choice B reason: Diffuse abdominal pain is nonspecific and occurs in various conditions, not uniquely appendicitis, which typically presents with localized right lower quadrant pain. Rebound tenderness is more diagnostic, as it directly reflects appendiceal inflammation, making it the priority finding.

Choice C reason: Decreased bowel sounds may occur in appendicitis due to ileus but are nonspecific, seen in other abdominal conditions. Rebound tenderness is more indicative, as it localizes to the appendix, confirming peritoneal irritation, critical for diagnosing acute appendicitis.

Choice D reason: Elevated blood pressure is not specific to appendicitis and may reflect pain or stress. Rebound tenderness directly indicates appendiceal inflammation, making it the most reliable finding, as it guides diagnosis and urgent intervention to prevent complications like perforation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Delegating oral care to UAP is appropriate for routine hygiene in AIDS patients with candidiasis. Leaving oral care solely to the nurse is unnecessary unless complex treatments are required. A soft-bristled toothbrush ensures safe, effective cleaning, supporting UAP involvement in standard oral hygiene.

Choice B reason: A soft-bristled toothbrush is ideal for oral care in candidiasis, as it gently cleans without traumatizing painful ulcers. In AIDS, oral hygiene reduces fungal load and discomfort. This instruction ensures safe, effective care by UAP, aligning with standard hygiene practices for mucosal infections.

Choice C reason: Sterile gloves are unnecessary for routine oral care, as candidiasis is not highly contagious in this context. Standard precautions, including clean gloves, suffice for UAP performing hygiene. Requiring sterile gloves is excessive, complicating care without added benefit compared to using a soft toothbrush.

Choice D reason: Mouthwash may irritate candidiasis ulcers, especially if alcohol-based, and is not the priority. Brushing with a soft-bristled toothbrush effectively cleans the mouth without causing trauma. Mouthwash is secondary and requires nurse oversight to ensure compatibility with the client’s condition, unlike brushing.

A. Increased urine output B. Elevated blood pressure C. Increased heart rate D. Weight gain

Correct Answer is A

Explanation

Choice A reason: Furosemide, a loop diuretic, promotes urine output by inhibiting sodium reabsorption in the kidneys, reducing fluid overload in heart failure. Increased urine output indicates effective diuresis, alleviating pulmonary and peripheral edema, making it the primary sign of therapeutic efficacy.

Choice B reason: Elevated blood pressure is not an expected effect of furosemide, which reduces preload and blood volume, often lowering pressure. Effective diuresis is shown by increased urine output, as this directly reflects fluid removal, critical for heart failure management.

Choice C reason: Increased heart rate is not a direct indicator of furosemide efficacy. Diuresis reduces cardiac workload, potentially stabilizing heart rate, but urine output is the primary measure, as it confirms fluid excretion, the medication’s main action in heart failure.

Choice D reason: Weight gain indicates fluid retention, the opposite of furosemide’s goal. Effective diuresis causes weight loss due to fluid excretion. Increased urine output is the key sign, as it directly measures the diuretic’s action in reducing heart failure-related fluid overload.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a client with suspected appendicitis. Which finding is most indicative of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

Correct Answer is B

Explanation

A client with a history of heart failure is prescribed furosemide. Which assessment finding indicates the medication is effective?

Correct Answer is A

Explanation

The nurse is caring for a client with type 2 diabetes mellitus who reports frequent episodes of hypoglycemia. Which action should the nurse prioritize?

A client presents with a temperature of 100°F (37.8°C) and reports difficulty breathing. Which intervention should the nurse implement first?

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?