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Exhibits

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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","D","E","F","H"]

Explanation

A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.

G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.

A. Serum electrolytes. B. Platelet count. C. Complete blood count. D. Liver enzymes.

Correct Answer is C

Explanation

A. Serum electrolytes are important to monitor in chronic kidney disease but do not directly relate to the effects of epoetin alfa.

B. Platelet count is not typically affected by epoetin alfa and does not directly address the client’s symptoms of tiredness.
C. Complete blood count (CBC) is crucial to monitor, especially hemoglobin and hematocrit levels, as epoetin alfa is used to treat anemia in chronic kidney disease, which can cause fatigue.
D. Liver enzymes are not directly related to the effects of epoetin alfa and the symptoms described.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

Correct Answer is ["A","D","E","F","H"]

Explanation

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

Correct Answer is C

Explanation

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Which is the best approach for the nurse to use when interviewing a client about sexual abuse?

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Exhibits

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