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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 C

Explanation

Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access. Inserting a central line would not address the underlying issue of compromised airway patency, and it would delay necessary interventions to secure the airway.

Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction. In the context of a client experiencing stridor, the priority is to ensure a patent airway, not to manage gastrointestinal issues. NGT insertion could potentially exacerbate airway compromise in a client with stridor.

Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation. This procedure is particularly important in cases where upper airway obstruction is suspected, such as swelling or hematoma formation following neck surgery.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction. The immediate concern for a client with stridor is ensuring a patent airway, and pacemaker placement would not resolve the airway compromise.

A. The stoma has streaks of bright red blood. B. There are no bowel sounds in the left lower quadrant. C. The fecal matter is brown and has a solid consistency. D. The stoma mucosa is purple in color.

Correct Answer is D

Explanation

Choice A reason: While streaks of bright red blood in the stoma can be concerning, it is not necessarily an immediate emergency. It may indicate minor trauma or irritation, but it does not require immediate surgical intervention unless accompanied by other symptoms.

Choice B reason: The absence of bowel sounds in the left lower quadrant can indicate a lack of intestinal activity, which may be a concern, but it is not an immediate surgical emergency. It requires monitoring and further assessment.

Choice C reason: Brown, solid fecal matter is a normal finding and indicates that the colostomy is functioning properly. This is not a cause for immediate concern.

Choice D reason: The stoma mucosa being purple in color is a critical finding that requires immediate reporting to the surgeon. Purple stoma mucosa can indicate compromised blood flow or ischemia, which can lead to tissue necrosis and serious complications if not addressed promptly.

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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

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?

Correct Answer is C

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?

Correct Answer is D

Explanation

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.

Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

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?

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

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.)

A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

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.