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

Answer and Explanation

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.

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Correct Answer is A

Explanation

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.

A. Rest and elevate the legs B. Apply direct heat to the affected area C. Engage in regular physical exercise D. Take over-the-counter painkillers

Correct Answer is C

Explanation

A) Incorrect - While resting and elevating the legs can provide relief for some vascular conditions, it may not effectively manage intermittent claudication. Resting during pain may help temporarily, but it does not address the underlying cause.

B) Incorrect - Applying direct heat to the affected area is not recommended for managing intermittent claudication. Heat may worsen the condition and should be avoided.

C) Correct - Regular physical exercise is the most appropriate intervention for managing intermittent claudication. Engaging in supervised exercise programs, such as walking, can improve peripheral circulation and reduce symptoms.

D) Incorrect - Over-the-counter painkillers may provide temporary relief but do not address the underlying cause of intermittent claudication. Relying solely on painkillers may lead to delayed diagnosis and treatment of PVD.

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A nurse is caring for a client after endovascular aneurysm repair (EVAR). What is the priority nursing intervention in the immediate postoperative period?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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