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Patient Data

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

Which goals should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Client education about diagnosis and plan of care

Effective coping with illness related anxiety

Promotion of bowel routine

Infection prevention related to illness

Relief of acute pain

Fluid volume management

A review of diet progression postoperatively

Prevention of deep vein thrombosis (DVT) related to immobility

Answer and Explanation

The Correct Answer is ["A","B","D","E","F"]

A. Client education about diagnosis and plan of care: Important for informed consent, cooperation, and reducing fear. The client is alert and oriented, so she should be provided with accurate information about appendicitis, surgical intervention, and next steps.

B. Effective coping with illness related anxiety: The client has a history of anxiety and reports feeling anxious during this episode. Addressing anxiety helps reduce sympathetic stimulation, supports emotional well-being, and improves overall cooperation with care.

C. Promotion of bowel routine: Not a current priority. The client’s bowel pattern is normal, and constipation is not contributing to the acute condition. Interventions should focus on the acute issue rather than chronic baseline management.

D. Infection prevention related to illness: Critical due to elevated WBC, fever, and confirmed appendicitis. Delayed or perforated appendicitis can lead to peritonitis or sepsis, so infection control is a top goal before and after surgery.

E. Relief of acute pain: A major priority as the client reports severe pain (9/10). Pain control improves comfort, reduces physiological stress responses, and is essential prior to surgical intervention.

F. Fluid volume management: The client has tachycardia, fever, and vomiting, placing her at risk for hypovolemia. The 1-liter lactated Ringer's bolus is essential to stabilize circulatory volume before anesthesia or surgery.

G. A review of diet progression postoperatively: Not a current focus in the ED. Nutritional education is typically addressed postoperatively when the client is recovering and cleared to resume oral intake.

H. Prevention of deep vein thrombosis (DVT) related to immobility: Important in longer-term or postoperative care, but not a priority during acute stabilization in the emergency setting before surgery.

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Correct Answer is B

Explanation

A. Monitor oxygen saturation via continuous pulse oximetry: While oxygen monitoring is important in any cardiac emergency, it does not address the underlying life-threatening cause. Tamponade requires urgent mechanical relief, not just oxygenation support.

B. Notify healthcare provider to prepare for pericardiocentesis: Cardiac tamponade is a medical emergency that restricts cardiac filling and output. Pericardiocentesis, which involves removing fluid from the pericardial sac, is the definitive and most urgent intervention to relieve pressure and prevent cardiovascular collapse.

C. Assess for paradoxical blood pressure: Measuring for pulsus paradoxus can help confirm tamponade but takes time and does not treat the condition. It should not delay notifying the provider for immediate intervention.

D. Observe neck for jugular vein distention: JVD is a common sign of tamponade but observing for it at this stage provides little new information. The presence of muffled heart sounds and restlessness already indicate that emergent treatment is necessary.

A. Inject exenatide within 30 minutes before or after a meal. B. There are no precautions about taking exenatide with other medications. C. Exenatide acts in the same way as insulin in lowering blood glucose. D. Notify your healthcare provider if you start having abdominal pain.

Correct Answer is D

Explanation

A. Inject exenatide within 30 minutes before or after a meal: Exenatide should be injected within 60 minutes before the morning and evening meals, not after, to mimic natural incretin hormone activity and optimize glucose control.
B. There are no precautions about taking exenatide with other medications: Exenatide can delay gastric emptying, which may affect the absorption of oral medications, especially antibiotics or contraceptives, so timing and interactions must be considered.
C. Exenatide acts in the same way as insulin in lowering blood glucose: Exenatide is not insulin; it is a GLP-1 receptor agonist that stimulates insulin release in response to meals and suppresses glucagon—its mechanism is different from direct insulin replacement.
D. Notify your healthcare provider if you start having abdominal pain: Severe abdominal pain may indicate pancreatitis, a rare but serious adverse effect of exenatide, and should be reported immediately for evaluation and possible discontinuation of the medication.

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Patient Data The nurse is stabilizing the client and preparing her for surgery. Which goals 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

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

Correct Answer is D

Explanation

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Patient Data

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

Which goals should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.