Based on the patient's current condition, the nurse recognizes that the patient's priority needs will be to prevent:
Cardiac dysrhythmias, Hypotension, and pain
Fluid and electrolyte imbalance, Hypotension, and Wound dehiscence
Inadequate diet, Wound dehiscence, Hypotension
Infection, Fluid and electrolyte imbalance, and pain
The Correct Answer is D
Choice A reason: Cardiac dysrhythmias are not the primary concern in a patient with acute cholecystitis. Although severe pain can lead to stress on the cardiovascular system, it is not the main priority in this scenario. Hypotension can be a concern due to dehydration from vomiting, but pain management is addressed more comprehensively under fluid and electrolyte balance and infection control.
Choice B reason: Wound dehiscence is not relevant in this case as the patient has not undergone surgery yet. Fluid and electrolyte imbalance and hypotension are important considerations due to the patient’s nausea and vomiting, but wound dehiscence does not apply to her current state of care.
Choice C reason: The inadequate diet is a consideration due to the patient's inability to eat or drink, and hypotension is a risk due to dehydration. However, wound dehiscence is still not relevant since the patient has not had a surgical procedure yet. Preventing an inadequate diet is part of the broader management but not the immediate priority.
Choice D reason: Infection, fluid and electrolyte imbalance, and pain are the most relevant concerns for a patient with acute cholecystitis. The nasogastric tube and IV fluids are vital for managing her dehydration and electrolyte imbalances. The patient's high pain level (9/10) indicates severe discomfort that must be managed effectively. Additionally, with the insertion of a nasogastric tube and the risk of cholecystitis-related complications, preventing infection is a key priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: 3% Normal Saline (3% NaCl) is not appropriate for treating acute Diabetes insipidus because it is hypertonic and can exacerbate dehydration, which is a primary concern in DI.
Choice B reason: Dextrose 5% in water (D5W) is appropriate for treating acute Diabetes insipidus as it provides free water without electrolytes, helping to correct the water deficit without causing electrolyte imbalances.
Choice C reason: Lactated Ringer's (LR) is not suitable for treating acute Diabetes insipidus because it contains electrolytes that can worsen the electrolyte imbalance in DI patients.
Choice D reason: Normal Saline (0.9% NaCl) can be used for treating acute Diabetes insipidus but it is not the most appropriate choice as it does not provide free water, which is needed to address the water deficit in DI patients.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Bleeding is a high-risk complication for patients with pancytopenia because of the low platelet count. Platelets are crucial for blood clotting, and their deficiency leads to an increased risk of spontaneous bleeding and difficulty in stopping bleeding once it starts. This can result in significant blood loss and complications if not managed promptly.
Choice B reason: Infection is another high-risk complication for patients with pancytopenia due to the low white blood cell count. White blood cells are essential for fighting infections, and their deficiency makes patients more susceptible to bacterial, viral, and fungal infections. These infections can be severe and difficult to control, leading to further complications and increased morbidity.
Choice C reason: Seizures are not typically associated with pancytopenia. Seizures are more commonly linked to neurological conditions, electrolyte imbalances, or other underlying medical issues rather than low blood cell counts.
Choice D reason: Neurogenic shock is not a common complication of pancytopenia. Neurogenic shock occurs due to a disruption in the autonomic nervous system, often resulting from spinal cord injuries or severe central nervous system damage, rather than low blood cell counts.
Choice E reason: Pulmonary edema is not directly related to pancytopenia. Pulmonary edema involves fluid accumulation in the lungs, often due to heart failure, kidney disease, or other causes, rather than low blood cell counts.
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