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 A
Explanation
A. The priority is to immediately intervene in the care being provided by the UAP and assess the client's condition to ensure prompt intervention if necessary.
B. While educating the UAP is important, immediate assessment and intervention for the client take precedence.
C. Investigating the reason for the UAP's actions can wait until after the client's condition has been assessed and stabilized.
D. Administering oral medications can wait until after the client's condition has been assessed and stabilized.
Correct Answer is ["B","H"]
Explanation
A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.
B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.
E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.
H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.
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.