# Situation: A 24-year-old woman comes to the emergency department with 14 hours of abdominal pain that began around the umbilicus and has moved to the right lower quadrant (RLQ). Anorexia and nausea started after the pain. Her temperature is 37.9 °C. She is sexually active, uses condoms, and says her last menstrual period, 3 weeks ago, was normal. The physician has completed her abdominal examination. While she waits for the surgeon, the following orders are received. Which order should the nurse clarify before carrying it out?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630381  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 24-year-old woman comes to the emergency department with 14 hours of abdominal pain that began around the umbilicus and has moved to the right lower quadrant (RLQ). Anorexia and nausea started after the pain. Her temperature is 37.9 °C. She is sexually active, uses condoms, and says her last menstrual period, 3 weeks ago, was normal.

The physician has completed her abdominal examination. While she waits for the surgeon, the following orders are received. Which order should the nurse clarify before carrying it out?

## 보기

1. Lactated Ringer's solution intravenously at 100 mL/h
2. Morphine 2 mg intravenously now for pain
3. Ceftriaxone and metronidazole intravenously before surgery
4. Bisacodyl suppository now for abdominal discomfort **✔ 정답**

**정답: 4**

## 해설

Laxatives and enemas are avoided in suspected appendicitis because increased peristalsis and pressure may cause perforation. Analgesia, including opioids, is appropriate and does not mask the diagnosis, and preoperative antibiotics and IV fluids are standard.

## 심화 해설

Why the bisacodyl order needs clarification
Her history is classic for acute appendicitis: pain that begins around the umbilicus, migrates to the right lower quadrant, and is followed by anorexia and nausea, with a low-grade temperature of 37.9 °C. In suspected appendicitis, laxatives and enemas are withheld because they increase peristalsis and intraluminal pressure, which may cause an inflamed, distended appendix to perforate. A bisacodyl suppository is a stimulant laxative, so this is the order the nurse questions with the prescriber before carrying it out. Clarifying an order is not refusing care; it is the nurse's responsibility to pause, check the rationale, and document the discussion when an order could harm the client.

The mechanism behind the danger
The appendix becomes inflamed when its lumen is obstructed. Mucus and bacteria accumulate behind the obstruction, pressure rises, venous drainage fails, and the wall becomes ischemic. A wall in this state tolerates very little extra stress. Stimulant laxatives and enemas add exactly that stress: stronger bowel contractions and higher pressure inside the colon and cecum. If the wall gives way, bowel contents spill into the peritoneal cavity and peritonitis follows, which turns a straightforward appendectomy into a far more serious illness. Heat applied to the abdomen is avoided for a similar reason, because it can increase blood flow to the inflamed tissue and speed rupture.

Why the other orders are appropriate
The remaining orders are standard preoperative care. Lactated Ringer's solution corrects the fluid deficit from vomiting, poor intake, and nothing-by-mouth (NPO) status, and it prepares the client for anesthesia. Morphine is appropriate: current practice is that analgesia, including opioids, does not mask the diagnosis or delay surgery. The older teaching that pain medicine should be withheld until the surgeon examines the client is outdated, and here the abdominal examination has already been completed. Ceftriaxone and metronidazole before surgery cover gram-negative and anaerobic bowel organisms and reduce wound and intra-abdominal infection.

| Order | Nursing judgment | Reason |
| --- | --- | --- |
| IV lactated Ringer's | Carry out | Replaces losses from vomiting and NPO status |
| IV morphine for pain | Carry out | Analgesia does not mask the diagnosis or delay surgery |
| Ceftriaxone + metronidazole | Carry out | Preoperative coverage of gram-negative and anaerobic organisms |
| Bisacodyl suppository | Clarify | Increased peristalsis and pressure may cause perforation |

Nursing care while awaiting surgery
While she waits, the nurse keeps her NPO, maintains the IV infusion, positions her for comfort (often semi-Fowler or with the knees slightly flexed), and reassesses pain, temperature, and heart rate. The nurse also watches for signs of rupture: sudden relief of pain followed by diffuse abdominal pain, rigidity, high fever, and tachycardia. Any of these is reported at once.

Exam takeaway
Key point In any question about suspected appendicitis, look for options that increase intra-abdominal pressure or bowel activity, such as laxatives, enemas, or a heating pad. These are the unsafe actions. Analgesia, IV fluids, and preoperative antibiotics are expected care, so an option that withholds pain relief to preserve the examination is usually the outdated distractor.

## 임상 시나리오

Suspected Appendicitis: Preoperative OrdersWhich order to question before surgery
Migrating periumbilical-to-RLQ pain with anorexia and nausea suggests acute appendicitis. The inflamed, obstructed appendix has a fragile wall that tolerates little added pressure.

Laxatives and enemas increase peristalsis and intraluminal pressure and may cause perforation, so a bisacodyl suppository is clarified with the prescriber. IV fluids, opioid analgesia, and preoperative ceftriaxone with metronidazole are standard care.

CautionWatch for sudden pain relief followed by diffuse abdominal pain, high fever, and tachycardia; this pattern suggests rupture and is reported at once. Avoid heat to the abdomen.

## 핵심 개념

- **Appendicitis** — Inflammation of the vermiform appendix, usually from luminal obstruction, causing periumbilical pain that migrates to the right lower quadrant.
- **Perforation** — Rupture of the inflamed appendiceal wall that releases bowel contents into the peritoneal cavity.
- **Stimulant laxative** — A drug such as bisacodyl that increases intestinal peristalsis to promote a bowel movement.
- **Clarifying an order** — Pausing to confirm a questionable prescription with the prescriber before carrying it out, to prevent harm.

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