A nurse is assessing a client suspected of having an abdominal aortic aneurysm (AAA). Which of the following physical assessment findings should the nurse prioritize?
Presence of a bruit over the abdominal area
Clubbing of the fingers
Decreased urinary output
Cyanosis of the extremities
The Correct Answer is A
A) Correct - The presence of a bruit (a turbulent blood flow sound) over the abdominal area is a priority finding when assessing for an AAA. It indicates possible turbulence caused by blood flow through the dilated artery and should be promptly reported for further evaluation.
B) Incorrect - Clubbing of the fingers is not a specific finding associated with AAA or peripheral vascular disorders. It may be related to respiratory or cardiac issues but is not relevant to this assessment.
C) Incorrect - Decreased urinary output may indicate kidney dysfunction or renal artery involvement in aneurysms, but it is not a priority finding compared to the presence of a bruit, which directly points to the aneurysm.
D) Incorrect - Cyanosis of the extremities may suggest compromised peripheral circulation, but it is not directly related to an AAA assessment. The presence of a bruit is more specific to aneurysm evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect - Assessing pain level at the insertion site is important but not the priority assessment when evaluating the immediate complications of femoral artery cannulation.
B) Correct - Assessing peripheral pulses distal to the insertion site is the priority when evaluating the adequacy of blood flow after femoral artery cannulation. Diminished or absent pulses may indicate vascular compromise.
C) Incorrect - The client's ability to ambulate independently is a relevant assessment but not the priority when immediately assessing the complications of femoral artery cannulation.
D) Incorrect - Capillary refill of the fingers is important but is not the priority assessment in the immediate post-procedure period following femoral artery cannulation.
Correct Answer is A
Explanation
A) Correct - After an endovascular stent graft placement for an AAA, clients should avoid heavy lifting for at least 2 weeks to prevent stress on the graft site and minimize the risk of complications.
B) Incorrect - Stopping all blood-thinning medications is not advisable after an endovascular stent graft placement. These medications may be prescribed to prevent blood clots around the graft site.
C) Incorrect - While follow-up CT scans are essential to monitor the success of the procedure and assess the aneurysm's stability, they are not expected to be frequent. The frequency of follow-up scans will be determined by the healthcare provider based on the client's progress.
D) Incorrect - Beginning a rigorous exercise routine immediately after the procedure is not recommended. Clients should gradually resume physical activity as guided by their healthcare provider to avoid complications and promote proper healing.
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