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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C"]

Explanation

A. Monitor the client's white blood cell count. WBC count is a key indicator of infection and helps monitor the severity of the infection.

B. Institute contact precautions for staff and visitors. MRSA is highly contagious and can be spread through direct contact, so contact precautions are necessary to prevent transmission.

C. Send wound drainage for culture and sensitivity. This is essential to identify the specific pathogen and determine the appropriate antibiotic treatment.

D. Explain the purpose of a low bacteria diet. While a low-bacteria diet is often recommended for immunocompromised patients, it is not a priority in this scenario, where infection management and isolation precautions are more urgent.

E. Use standard precautions and wear a mask. Standard precautions should always be used, but a mask is not necessary unless the client has respiratory symptoms, which is not indicated in this case.

A. Notify healthcare provider to prepare for pericardiocentesis. B. Assess for paradoxical blood pressure C. Observe neck for jugular vein distention. D. Monitor oxygen saturation via continuous pulse oximetry.

Correct Answer is A

Explanation

A. Cardiac tamponade is a life-threatening condition that requires urgent intervention, typically pericardiocentesis to relieve pressure on the heart. Immediate notification to the healthcare provider for preparation of this procedure is the priority.
B. Paradoxical blood pressure (a drop in systolic BP during inspiration) is a key sign of cardiac tamponade, but the most important action is to prepare for pericardiocentesis.
C. Jugular vein distention can be a sign of tamponade, but pericardiocentesis is the priority to address the underlying cause of the symptoms.
D. While monitoring oxygen saturation is important, it is not the most critical action in this emergency situation.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin- resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is A

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

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Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by dropdown, dropdown, and dropdown.

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.