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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Administering antipyretic medication as needed

Educating client and family on the importance of fluid restrictions

Collaborating with dietician to prepare low protein diet

Monitoring fluid status

Investigating acid/base complication

Assessing for worsening respiratory status

Performing diagnostic testing to determine cause of fever

Reassessing vital signs

Identifying cardiac arrhythmias

Answer and Explanation

Correct Answer : D,F,I

A.   Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B.   Client and family education on fluid management is important but can be addressed after assessing hydration status.
C.   Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D.   Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E.   The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F.   The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G.   Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H.   Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I.   The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

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Correct Answer is ["B","C","G","H"]

Explanation

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.

A. Working with an addiction therapist for several months will assist in my recovery. B. The Alcoholics Anonymous program would be a great resource, but they do not have meetings when I'm free. C. It is not safe for me to drink alcohol, but I am still able to smoke marijuana without problems. D. Identifying potential triggers allows me to proactively utilize coping strategies. E. Relapse is an expected complication of substance use; thus, prevention strategies and awareness of my emotions are important. F. The treatment options for alcoholism are limited to inpatients, with very few resources for outpatients.

Correct Answer is ["A","D","E"]

Explanation

Rationale:

1. Working with an addiction therapist for several months will assist in my recovery. This statement reflects an acknowledgment of the importance of therapy in her recovery process, indicating an understanding of the treatment plan.
2. The Alcoholics Anonymous program would be a great resource, but they do not have meetings when I'm free.
While it acknowledges AA as a resource, it doesn't show an understanding of prioritizing meetings or seeking alternative solutions.
3. It is not safe for me to drink alcohol, but I am still able to smoke marijuana without problems.
This indicates a misconception; if alcohol is unsafe, other substances likely are too.

4. Identifying potential triggers allows me to proactively utilize coping strategies.

This statement demonstrates an understanding of the importance of identifying triggers and implementing coping strategies to prevent relapse, indicating engagement in the treatment process.
5. Relapse is an expected complication of substance use; thus, prevention strategies and awareness of my emotions are important.
Acknowledging relapse as a potential complication and recognizing the importance of prevention strategies and emotional awareness indicates a realistic understanding of the challenges associated with recovery.

6. The treatment options for alcoholism are limited to inpatients, with very few resources for outpatients.
This is factually incorrect and doesn't show understanding of the variety of treatment options available.

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Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

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Naxlex Comprehensive Predictor Exams

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Correct Answer is ["B","C","G","H"]

Explanation

Correct Answer is ["A","D","E"]

Explanation

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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?