Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Fluid volume excess.

Risk for infection.

Ineffective thermoregulation.

Pain.

Answer and Explanation

The Correct Answer is A

Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.

Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.

Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.

Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.

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Correct Answer is D

Explanation

Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.

Giving food and fluids to a client with POI may worsen the condition and cause complications.

Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.

Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.

Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.

Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.

A. The lack of healing of the stump. B. Ineffective control of the client’s pain. C. The removal of the wrong arm. D. The client being mildly sedated.

Correct Answer is C

Explanation

This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.

Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.

Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.

Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.

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Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

Correct Answer is D

Explanation

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Correct Answer is C

Explanation

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