Exhibits
The nurse is stabilizing the client and preparing her for surgery.
What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.
Effective coping with illness related anxiety
Infection prevention related to illness
Relief of acute pain
A review of diet progression postoperatively
Promotion of bowel routine
Prevention of deep vein thrombosis (DVT) related to immobility
Fluid volume management
Client education about diagnosis and plan of care
Correct Answer : B,C,G,H
A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume. Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Holding hands below elbows when rinsing is correct to prevent contamination.
B. Washing for at least 20 seconds is appropriate.
C. Turning off the faucet with bare hands can lead to recontamination. A paper towel should be used to turn off the faucet.
D. Lathering using a circular movement is correct technique.
Correct Answer is D
Explanation
A. Provide the client written information about end-of-life care.
Although educating patients is a fundamental nursing duty, distributing pamphlets is a task-oriented activity that does not support "continuity of care." The client may be emotionally or physically worn out at the time of transfer. It is early and lacks the essential clinical handoff between specialists to provide them documentation before developing a therapeutic relationship or comprehending their current problems.
B. Mark the chart with client's request for no heroic measures.
This document outlines the need for thorough documentation and clerical work in clinical settings, emphasizing its importance for safety by preventing undesirable outcomes. It highlights that while the act of documentation is static, the process of continuity of care is dynamic. Specifically, it notes that simply marking a chart does not adequately communicate critical information such as the client's discomfort level, medication schedule, or emotional state regarding their child.
C. Reassure the client that the client's child will be allowed to visit.
This psychosocial intervention is outstanding. This is a significant cause of worry for a parent of a small child. On the other hand, "continuity of care" describes the more comprehensive transfer of the nursing and medical plan. Until you have the whole report on the client's status and the capabilities of the unit, you cannot properly reassure the client about certain unit policies (such as kid visitation in a sterile or restricted area).
D. Obtain a detailed report from the nurse transferring the client.
This is the gold standard for Continuity of Care. A professional handoff (usually via SBAR) ensures that the receiving nurse knows exactly where the previous nurse left off.
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