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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Quad coughing is a technique used to help patients with spinal cord injuries improve their coughing ability, but it does not directly prevent autonomic dysreflexia. While it is beneficial for respiratory health, it is not the primary intervention for preventing autonomic dysreflexia.
Choice B reason: Assisting to plan a prescribed bowel program is crucial in preventing autonomic dysreflexia. Bowel impaction is a common trigger for autonomic dysreflexia, and a regular bowel program helps to prevent constipation and ensure regular bowel movements, reducing the risk of this complication.
Choice C reason: Supporting the selection of a high-protein diet is important for overall health and nutrition, but it does not directly prevent autonomic dysreflexia. While proper nutrition is essential for patients with spinal cord injuries, it is not the primary intervention for preventing autonomic dysreflexia.

A. Cyanosis and hypertension. B. Dysrhythmias and expiratory wheezing. C. Pulmonary edema and fibrosis. D. Dyspnea and increased heart rate.

Correct Answer is D

Explanation

Choice A reason: Cyanosis and hypertension are not typically associated with severe anemia. While anemia can lead to tissue hypoxia, cyanosis is more related to respiratory or cardiovascular problems, and hypertension is not a common consequence of anemia.
Choice B reason: Dysrhythmias and expiratory wheezing are not directly related to severe anemia. Dysrhythmias can occur in severe cases due to the heart's increased workload, but expiratory wheezing is generally associated with respiratory conditions like asthma or chronic obstructive pulmonary disease (COPD).
Choice C reason: Pulmonary edema and fibrosis are not linked to severe anemia. These conditions are related to heart failure, lung injury, or chronic lung diseases, rather than anemia.
Choice D reason: Dyspnea and increased heart rate are expected findings in a severely anemic patient. Dyspnea, or difficulty breathing, occurs because the body is not getting enough oxygen due to the reduced number of red blood cells. The heart rate increases as a compensatory mechanism to deliver more oxygenated blood to the tissues.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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