Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

The nurse is stabilizing the client and preparing her for surgery.
Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Infection prevention related to appendicitis

Relief of acute pain

Client education about diagnosis and plan of care

Effective coping with illness-related anxiety

Prevention of deep vein thrombosis related to immobility

Promotion of bowel routine

Fluid volume management

Answer and Explanation

Correct Answer : A,B,C,D,G

Choice A reason:

Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.

Choice B reason:

Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.

Choice C reason:

Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.

Choice D reason:

Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.

Choice G reason:

Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are typically signs of neurogenic shock, which occurs immediately after a spinal cord injury. However, autonomic dysreflexia is characterized by severe hypertension, not hypotension. The symptoms in this scenario do not fit the presentation of autonomic dysreflexia.

Choice B reason: Reports of chest pain and shortness of breath are not the primary symptoms of autonomic dysreflexia. While autonomic dysreflexia can cause a variety of symptoms due to uncontrolled sympathetic nervous system activity, the hallmark symptoms are severe hypertension and headache, along with other specific signs like diaphoresis.

Choice C reason: Pain and a burning sensation upon urination and hematuria indicate a urinary tract infection or another urological issue, not autonomic dysreflexia. While a full bladder is a common trigger for autonomic dysreflexia, the symptoms described in this choice do not accurately reflect the condition.

Choice D reason: Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia. This condition results from an overactive autonomic nervous system response to stimuli below the level of the injury, such as a full bladder. The resulting vasoconstriction leads to severe hypertension and symptoms like headache and sweating above the level of injury.

A. Reports of a bad taste in the mouth. B. Low concentrated urine output. C. Dyspnea and sinus tachycardia. D. Productive cough and fever.

Correct Answer is C

Explanation

Choice A reason: Reports of a bad taste in the mouth can be associated with various conditions, including metabolic imbalances, but it is not typically an immediate concern in the context of AKI.

Choice B reason: Low concentrated urine output (oliguria) is a common finding in AKI and indicates decreased kidney function. While it is an important assessment finding, it does not usually require immediate intervention compared to signs of severe complications.

Choice C reason: Dyspnea (difficulty breathing) and sinus tachycardia (rapid heart rate) can indicate fluid overload or pulmonary edema, which are serious complications of AKI. These symptoms require immediate intervention to prevent respiratory distress and potential cardiac complications.

Choice D reason: A productive cough and fever may suggest an infection, which is important to address but not necessarily an immediate life-threatening issue compared to dyspnea and tachycardia in the context of AKI.

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

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is D

Explanation

A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

Correct Answer is C

Explanation

A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?

A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

A nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

Exhibits

The nurse is stabilizing the client and preparing her for surgery.
Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.