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 B
Explanation
A) Incorrect - Regular physical exercise is not a risk factor for aneurysms. In fact, it is associated with a reduced risk of various cardiovascular diseases, including some peripheral vascular disorders.
B) Correct - Hypertension is a significant risk factor for the development of aneurysms. Elevated blood pressure can weaken arterial walls, increasing the risk of aneurysm formation and rupture.
C) Incorrect - A low LDL level below 100 mg/dL is generally considered a healthy lipid profile and is not a risk factor for aneurysms. However, high LDL levels are associated with atherosclerosis and peripheral vascular disorders.
D) Incorrect - A vegetarian diet is not a risk factor for aneurysms. In fact, a diet rich in fruits, vegetables, and whole grains may reduce the risk of cardiovascular diseases, including aneurysms.
Correct Answer is D
Explanation
A) Incorrect - Deep breathing exercises are not appropriate for sudden, severe, tearing chest pain in a client with a known TAA. This type of pain may indicate aortic dissection, a medical emergency.
B) Incorrect - Taking an over-the-counter painkiller may temporarily relieve the pain, but it will not address the underlying issue. The priority action is to seek medical attention immediately.
C) Incorrect - Lying down and resting is not appropriate for sudden, severe, tearing chest pain associated with a TAA. This type of pain requires urgent evaluation by healthcare professionals.
D) Correct - Seeking immediate medical attention is crucial for a client experiencing sudden, severe, tearing chest pain associated with a TAA. This presentation may indicate aortic dissection, a life-threatening complication.
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