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 ["40"]
Explanation
Single dose: 500 mg
Volume per single dose: 500 mg / (250 mg/5 mL) = 10 mL
Total daily volume: 10 mL/dose * 4 doses/day = 40 mL/day
Therefore, the child should receive 40 mL of ampicillin suspension per day.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Describing heart rate patterns: Fetal heart rate patterns are essential indicators of the fetus's response to labor. By teaching the client about these patterns, the nurse can help the client understand what is normal and what may signal potential distress, helping to alleviate anxiety and provide education during labor.
Continuous fetal monitoring: Continuous fetal monitoring is a key tool for assessing the fetus's well-being during labor. It helps the nurse track the fetal heart rate and identify any abnormal patterns that could indicate fetal distress, such as late decelerations or significant variability.
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