A nurse is caring for a client after endovascular aneurysm repair (EVAR). What is the priority nursing intervention in the immediate postoperative period?
Administering intravenous pain medication
Monitoring for signs of graft occlusion
Encouraging the client to cough and deep breathe
Checking vital signs every 4 hours
The Correct Answer is B
A) Incorrect - Administering intravenous pain medication is important for the client's comfort but is not the priority in the immediate postoperative period after EVAR.
B) Correct - Monitoring for signs of graft occlusion is the priority in the immediate postoperative period after EVAR. Graft occlusion can lead to severe complications and requires prompt intervention.
C) Incorrect - Encouraging the client to cough and deep breathe is important for postoperative lung expansion, but it is not the priority when compared to monitoring for graft occlusion after EVAR.
D) Incorrect - Checking vital signs every 4 hours is a standard nursing intervention, but it is not the priority in the immediate postoperative period after EVAR, especially when graft occlusion may pose a more immediate threat.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - During a venous Doppler ultrasound, the transducer emits sound waves that create a warm sensation as it moves across the skin. This is a normal and common experience during the test.
B) Incorrect - Unlike some procedures that require fasting, a venous Doppler ultrasound does not require the client to be NPO.
C) Incorrect - While removing metal jewelry is necessary for certain imaging tests like an MRI, it is not typically required for a venous Doppler ultrasound.
D) Incorrect - Bending the knees during a venous Doppler ultrasound does not interfere with the procedure. The client can usually lie in a comfortable position during the test.
Correct Answer is B
Explanation
A) Incorrect - Encouraging early ambulation and leg exercises is essential after peripheral artery bypass surgery to promote blood circulation and prevent complications like deep vein thrombosis.
B) Correct - Elevating the affected leg above heart level while resting can help reduce swelling and promote blood flow, aiding in the healing process after peripheral artery bypass surgery.
C) Incorrect - Applying direct pressure to the surgical incision if it starts bleeding may worsen the bleeding. Instead, the client should apply gentle pressure with a clean cloth and seek immediate medical attention if bleeding does not stop.
D) Incorrect - Taking hot baths is not recommended after peripheral artery bypass surgery. Heat may dilate blood vessels and increase blood flow, potentially causing complications at the surgical site.
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