Exhibits
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 []
Explanation
Potential Condition: Anthrax
The client's flu-like symptoms followed by shortness of breath, cough, and chest pain align with potential inhalation anthrax. Furthermore, working in a government building and opening a suspicious package containing white powder suggests potential exposure to anthrax spores.
Actions to Take:
Place the client in isolation - Isolating the client helps prevent potential transmission of anthrax to others.
Apply oxygen via nasal cannula: The client's low oxygen saturation (88%) necessitates oxygen therapy to improve oxygen delivery to tissues.
Parameters to Monitor:
Arterial blood gases - Monitoring arterial blood gases helps assess the client's respiratory status and oxygenation levels, which may be compromised in anthrax-related respiratory distress.
Breath sounds - Monitoring breath sounds helps assess the effectiveness of respiratory interventions and detect any changes indicative of worsening respiratory status.
Correct Answer is D
Explanation
A. While chewing food well is important to aid digestion and prevent discomfort, meal timing and portion control are the primary concerns in gastric bypass patients.
B. Sipping fluids slowly is important, but fluids should generally be taken between meals rather than with meals to prevent stretching the stomach pouch and to avoid dumping syndrome.
C. Reducing fatty and gas-forming foods can help avoid discomfort, but this is less critical than ensuring proper food breakdown through thorough chewing.
D. After gastric bypass surgery, small, frequent meals help prevent dumping syndrome, a condition in which food moves too quickly from the stomach to the small intestine, causing nausea, dizziness, and diarrhea. Portion control is essential to avoid overstretching the reduced stomach pouch and ensure adequate nutrient absorption.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
