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Exhibits

The nurse is stabilizing the client and preparing her for surgery.

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

Effective coping with illness related anxiety

Infection prevention related to illness

Relief of acute pain

A review of diet progression postoperatively

Promotion of bowel routine

Prevention of deep vein thrombosis (DVT) related to immobility

Fluid volume management

Client education about diagnosis and plan of care

Answer and Explanation

Correct Answer : B,C,G,H

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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is []

Explanation

Potential condition:

TACO is a complication that can occur during or shortly after a blood transfusion, particularly in children. It happens when the volume of blood infused exceeds the circulatory system's ability to handle it, leading to fluid overload. In this case, the child is receiving 250 mL of packed red blood cells (PRBCs), and there are signs that the child may be experiencing fluid overload, such as tachycardia, hypotension, headache, and flushing. The elevated heart rate (115 beats/minute) and low blood pressure (88/44 mm Hg) after the transfusion started suggest that the child may be at risk for circulatory overload. These symptoms, combined with the increased temperature (100.9°F, 38.3°C), further support the likelihood of TACO.

Actions to Take:

Stop the blood transfusion: This is the first and most important step when transfusion-related complications, such as TACO, are suspected. Stopping the transfusion immediately helps to prevent further exacerbation of the fluid overload, which could lead to worsening respiratory distress and circulatory compromise.

Administer an antipyretic: The child has developed a fever (100.9°F), which could be a response to the transfusion. Administering an antipyretic such as acetaminophen or ibuprofen can help manage the fever, provide comfort, and prevent further complications. Fever management is important, especially in transfusion reactions, as it helps reduce the risk of complications such as febrile non-hemolytic transfusion reactions (FNHTR).

Parameters to Monitor:

Blood pressure: Monitoring the blood pressure is critical in assessing the child’s circulatory status. A low blood pressure (88/44 mm Hg), especially in the context of tachycardia, indicates that the child is experiencing hypotension, which is often associated with circulatory overload. Close monitoring of blood pressure will help guide the decision to start appropriate treatments, such as diuretics, to manage the overload.

Hematocrit: The hematocrit value provides information about the oxygen-carrying capacity of the blood. Given that the child’s hemoglobin was 6.5 g/dL (65 g/L) prior to the transfusion, it’s important to continue monitoring the hematocrit to assess the effectiveness of the PRBC transfusion. If the hematocrit remains low despite transfusion, it could indicate an ongoing issue with blood volume or oxygen delivery to tissues.

Correct Answer is []

Explanation

Condition Most Likely Experiencing: Malignant Hyperthermia

The client's tachycardia (HR 134/min), tachypnea (RR 28/min), hypotension (BP 92/52 mm Hg), and hypoxia (SpO₂ 89%) are key signs of malignant hyperthermia (MH), a life-threatening reaction to general anesthesia.
While hyperthermia (elevated temperature) is a late sign, the presence of early indicators like tachycardia, tachypnea, and hypoxia strongly suggests MH.
Incorrect choices:
- Paralytic ileus (A): This is a possible secondary complication but not the primary issue.
- Nausea and vomiting (B): Common post-op symptoms, but they don’t explain the severe vitals.
- Hypercapnia (C): The client is hyperventilating, not hypoventilating.
- Latex allergy (E): No signs of urticaria, anaphylaxis, or bronchospasm, which would indicate a latex allergy.

Correct Answer: Malignant hyperthermia

Two Actions to Take:

Administer dantrolene (C)
- Dantrolene is the only effective antidote for MH. It directly relaxes skeletal muscles and stops the uncontrolled muscle metabolism that drives the crisis.
Monitor muscle rigidity (E)
- Muscle rigidity is a hallmark sign of MH, especially in the jaw and upper body. The nurse must monitor for worsening rigidity as an indicator of disease progression.

Incorrect choices:
- Obtain the latex-free cart (A): There is no indication of a latex allergy.
- Administer ondansetron (B): Useful for nausea and vomiting but does not address MH.
- Insert an NG tube (D): Might be needed for paralytic ileus but is not a priority in treating MH.

Correct Answers: Administer dantrolene, Monitor muscle rigidity

Two Parameters to Monitor:

Bowel sounds (C)
- Paralytic ileus can develop as a secondary complication of MH due to decreased blood flow to the intestines during the crisis. Monitoring bowel sounds helps detect this issue early.
Muscle rigidity (E)
- Since sustained muscle contractions are a key feature of MH, tracking muscle rigidity helps assess whether the crisis is worsening or improving.

Incorrect choices:
- Blood pressure (A): While important, it is not a specific marker for MH progression.
- Urine output (B): Useful for assessing kidney function but not directly related to MH management.
- Skin integrity (D): Not a priority in this emergency.

Correct Answers: Bowel sounds, Muscle rigidity

Summary of Correct Answers:

Condition Most Likely Experiencing: Malignant hyperthermia
Two Actions to Take:Administer dantrolene, Monitor muscle rigidity
Two Parameters to Monitor: Bowel sounds, Muscle rigidity

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Correct Answer is []

Explanation

Summary of Correct Answers:

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Exhibits

The nurse is stabilizing the client and preparing her for surgery.

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