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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 C

Explanation

A. Intubation is not the first step unless the client's respiratory status continues to deteriorate despite oxygen therapy.

B. Obtaining a sputum culture may be helpful but does not address the immediate respiratory compromise.

C. A nonrebreather mask with 100% oxygen provides high-flow oxygen and is essential for a client with worsening dyspnea and low oxygen saturation.

D. A forward-leaning position may help with breathing but does not provide the necessary oxygen support in this acute situation.

A. Slow weight loss. B. Muscle weakness. C. Leg numbness. D. Cold sensitivity.

Correct Answer is D

Explanation

A. Slow weight loss: Weight changes can occur due to many reasons but are not an immediate indicator of thyroid dysfunction.
B. Muscle weakness: This could be related to thyroid dysfunction, but it is not as specific as cold sensitivity.
C. Leg numbness: Numbness might be related to various conditions, but it is not directly related to thyroid dysfunction.
D. Cold sensitivity: This is a classic sign of hypothyroidism, which can occur in postmenopausal women. A referral for thyroid testing is needed to rule out thyroid dysfunction.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

Correct Answer is D

Explanation

The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. Which information should the nurse provide?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

Exhibits According to the lab values, the client has dropdownrelated to dropdownordropdown.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

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.