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. Sit the client up and provide supplemental oxygen is the correct priority intervention. Chest pain and shortness of breath can be indicative of pulmonary embolism or other respiratory complications, which require immediate attention. Sitting the client up helps improve respiratory mechanics, and providing supplemental oxygen can support oxygenation while further assessments are conducted.
B. While contacting the physician and obtaining an arterial blood gas may be necessary to assess respiratory status and oxygenation, it is not the immediate priority. The client's symptoms require immediate intervention to ensure adequate oxygenation and prevent further deterioration.
C. Chest pain and shortness of breath are not typically expected findings after bariatric surgery and could indicate serious complications. It is essential not to dismiss the client's symptoms but to take them seriously and initiate appropriate interventions.
D. While the use of an incentive spirometer is important for preventing respiratory complications after surgery, it is not the priority intervention in this situation. The client's current symptoms require immediate attention to address potential respiratory distress or other serious complications.

A. Blurred vision, weakness, tingling of extremities B. Hunger, shakiness, confusion C. Thirst, polyuria, abdominal pain D. Tachycardia, oliguria, anxiety

Correct Answer is C

Explanation

C. Thirst, polyuria, and abdominal pain are symptoms commonly associated with hyperglycemia. High blood glucose levels can lead to osmotic diuresis, causing increased urination and thirst. Abdominal pain may occur due to gastrointestinal symptoms related to hyperglycemia, such as bloating or discomfort.
A. Blurred vision, weakness, tingling of extremities are more indicative of hypoglycemia rather than hyperglycemia.
B. Hunger, shakiness, confusion are symptoms of hypoglycemia rather than hyperglycemia.
D. While tachycardia and anxiety can occur with various medical conditions, oliguria is not typically associated with hyperglycemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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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?