Patient Data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Anthrax

The client's flu-like symptoms followed by shortness of breath, cough, and chest pain align with potential inhalation anthrax. Furthermore, working in a government building and opening a suspicious package containing white powder suggests potential exposure to anthrax spores.
Actions to Take:

Place the client in isolation - Isolating the client helps prevent potential transmission of anthrax to others.
Apply oxygen via nasal cannula: The client's low oxygen saturation (88%) necessitates oxygen therapy to improve oxygen delivery to tissues.

Parameters to Monitor:

Arterial blood gases - Monitoring arterial blood gases helps assess the client's respiratory status and oxygenation levels, which may be compromised in anthrax-related respiratory distress.
Breath sounds - Monitoring breath sounds helps assess the effectiveness of respiratory interventions and detect any changes indicative of worsening respiratory status.

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Correct Answer is B

Explanation

A. A hard, painless nodule may indicate a deformity but is not an emergency.

B. Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C. Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D. Painful corns and calluses are chronic issues that need management but are not urgent.

A. Effective coping with illness related anxiety B. Infection prevention related to illness C. Relief of acute pain D. A review of diet progression postoperatively E. Promotion of bowel routine F. Prevention of deep vein thrombosis (DVT) related to immobility G. Fluid volume management H. Client education about diagnosis and plan of care

Correct Answer is ["B","C","G","H"]

Explanation

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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Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

Correct Answer is B

Explanation

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

Correct Answer is ["B","C","G","H"]

Explanation

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

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Patient Data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.