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 C
Explanation
A) Incorrect - While regular aerobic exercise is beneficial for overall vascular health, it may not specifically alleviate Raynaud's disease symptoms during cold weather.
B) Incorrect - Applying a heating pad to the affected areas is not the most effective intervention for managing Raynaud's disease symptoms. It may not fully address the underlying vascular constriction.
C) Correct - Avoiding exposure to cold temperatures is essential for managing Raynaud's disease symptoms. Cold temperatures can trigger vasospasm in affected areas, leading to color changes and discomfort.
D) Incorrect - Over-the-counter antihistamines are not a standard treatment for Raynaud's disease and may not directly alleviate symptoms related to cold weather exposure.
Correct Answer is C
Explanation
A) Incorrect - Angiography is a diagnostic test used to visualize blood vessels after the injection of a contrast medium. While it can assess blood flow, it is not the most common test for PVD.
B) Incorrect - An electrocardiogram (ECG) is used to assess the electrical activity of the heart and is not specific to PVD or lower extremity blood flow.
C) Correct - The ankle-brachial index (ABI) is the most commonly used test to assess blood flow in the lower extremities for PVD. It compares blood pressure measurements at the ankle and arm to determine peripheral artery occlusive disease.
D) Incorrect - A lumbar puncture is not used to assess blood flow in the lower extremities. It is a procedure for obtaining cerebrospinal fluid for diagnostic purposes in certain neurological conditions.
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