A nurse is caring for a client post-abdominal aortic aneurysm repair. What is the priority nursing action to detect potential complications?
Monitoring hourly urine output
Assisting with early ambulation
Assessing pedal pulses bilaterally
Monitoring blood glucose levels
The Correct Answer is C
A) Incorrect - While monitoring urine output is essential, it is not the priority for a client post-abdominal aortic aneurysm repair. Other assessments take precedence to detect immediate complications.
B) Incorrect - Assisting with early ambulation is important for postoperative recovery, but it is not the priority when there might be a risk of complications from the surgery.
C) Correct - Assessing pedal pulses bilaterally is the priority nursing action post-abdominal aortic aneurysm repair. Diminished or absent pedal pulses could indicate compromised blood flow to the lower extremities, possibly due to a clot or embolism.
D) Incorrect - Monitoring blood glucose levels is relevant for some clients, but it is not the priority in this situation, unless the client has a specific history of diabetes or altered glucose levels that could impact their recovery.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect - Complete fasting is typically not required for an angioplasty procedure. The client may receive specific instructions about food and drink restrictions, but a 24-hour fasting period is unnecessary.
B) Incorrect - Angioplasty is not associated with chest pain. It is primarily performed to improve blood flow in narrowed or blocked arteries, such as those in the legs in PAD.
C) Incorrect - Angioplasty is usually performed with local anesthesia, not general anesthesia. The client will be awake but may receive sedation to help them relax during the procedure.
D) Correct - After the procedure, the client is typically advised to lie flat and keep the leg straight for several hours to prevent bleeding and promote vessel healing. This position helps to apply pressure at the site of the angioplasty.
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.
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