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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Administering antipyretic medication as needed

Educating client and family on the importance of fluid restrictions

Collaborating with dietician to prepare low protein diet

Monitoring fluid status

Investigating acid/base complication

Assessing for worsening respiratory status

Performing diagnostic testing to determine cause of fever

Reassessing vital signs

Identifying cardiac arrhythmias

Answer and Explanation

Correct Answer : D,F,I

A.   Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B.   Client and family education on fluid management is important but can be addressed after assessing hydration status.
C.   Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D.   Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E.   The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F.   The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G.   Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H.   Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I.   The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

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Correct Answer is B

Explanation

A. A blood alcohol level of 0.09% indicates intoxication but is less immediately critical than lithium toxicity.
B. A serum lithium level of 1.6 mEq/L indicates lithium toxicity, which can be life- threatening and requires immediate medical intervention.
C. Significant weight loss is concerning but not as acute an issue as potential lithium toxicity.
D. Lack of sleep is serious but is a symptom that can be managed; it is not as urgent as addressing potential lithium toxicity.

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 The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?