NCLEX-RN
Gastrointestinal NCLEX RN Questions Questions
Extract:
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Notes
0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
Laboratory Results
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
Question 1 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: B: Appendicitis; A: Insert a peripheral VAD, prepare the client for surgery; C: Temperature, pulse
Rationale: The clinical presentation (right lower quadrant pain, fever, leukocytosis, rigid abdomen) strongly suggests appendicitis (
B). Inserting a VAD and preparing for surgery (
A) are critical for anticipated appendectomy. Monitoring temperature and pulse (
C) tracks infection and hemodynamic status.
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Question 2 of 5
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