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Exhibits

The nurse is stabilizing the client and preparing her for surgery.
Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Infection prevention related to appendicitis

Relief of acute pain

Client education about diagnosis and plan of care

Effective coping with illness-related anxiety

Prevention of deep vein thrombosis related to immobility

Promotion of bowel routine

Fluid volume management

Answer and Explanation

Correct Answer : A,B,C,D,G

Choice A reason:

Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.

Choice B reason:

Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.

Choice C reason:

Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.

Choice D reason:

Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.

Choice G reason:

Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.

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Correct Answer is D

Explanation

Choice A reason: Comparing the capillary refill in the hands is a useful assessment for evaluating peripheral circulation, but it is not specific to diagnosing carpal tunnel syndrome. Carpal tunnel syndrome involves compression of the median nerve, and capillary refill does not provide information about nerve compression.

Choice B reason: Determining the client's sleeping position may provide insight into factors that exacerbate symptoms, but it does not directly assess for carpal tunnel syndrome. While certain positions might worsen the condition, this information alone is not diagnostic.

Choice C reason: Applying firm pressure over the ulnar artery is not relevant to assessing carpal tunnel syndrome. The ulnar artery supplies blood to the hand, but carpal tunnel syndrome involves the median nerve, not the ulnar artery.

Choice D reason: Tapping the client's wrists to locate the pain, known as Tinel's sign, is a specific test for carpal tunnel syndrome. Tinel's sign is positive when tapping over the median nerve at the wrist elicits tingling or pain in the fingers, indicating nerve compression.

A. Overall fluid intake. B. Citrus fruit juices. C. Low-sodium sodas. D. Tea and hot chocolate.

Correct Answer is B

Explanation

Choice A reason: Overall fluid intake should not be limited. In fact, increasing fluid intake is generally recommended to help flush out the urinary system and prevent the formation of new stones. Adequate hydration is key to preventing urinary tract calculi.

Choice B reason: Citrus fruit juices, such as orange juice and grapefruit juice, should be limited because they can increase the acidity of the urine. High acidity can contribute to the formation of certain types of kidney stones, particularly uric acid stones. Limiting citrus fruit juices can help reduce the risk of stone recurrence.

Choice C reason: Low-sodium sodas are generally better than regular sodas, but it is important to note that many sodas, even low-sodium ones, contain high levels of phosphates and other substances that can contribute to kidney stone formation. While low-sodium sodas are a better option, the primary focus should be on overall healthy fluid choices.

Choice D reason: Tea and hot chocolate should be limited due to their oxalate content. Oxalates can bind with calcium in the urine to form calcium oxalate stones, which are the most common type of kidney stones. Limiting the intake of tea and hot chocolate can help reduce the risk of stone formation.

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Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to wake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

Correct Answer is D

Explanation

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing fluid intake, the nurse should include which type of fluid limitation?

Correct Answer is B

Explanation

The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure:

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

Exhibits The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the carcinogens, which statement indicates an accurate understanding?

Exhibits

The nurse is stabilizing the client and preparing her for surgery.
Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.