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 C
Explanation
A) Incorrect - Thrombosis (formation of a blood clot within the vessel) is a potential complication of various peripheral vascular aneurysms, including popliteal artery aneurysms.
B) Incorrect - Embolization (dislodgment of a blood clot or debris) is a potential complication of various peripheral vascular aneurysms, including popliteal artery aneurysms.
C) Correct - Venous stasis (poor venous blood flow) is a unique complication of popliteal artery aneurysms. The aneurysm can compress surrounding veins, leading to venous stasis and its consequences.
D) Incorrect - Atherosclerosis (build-up of plaque within the artery) is a general complication of many peripheral vascular disorders, not unique to popliteal artery aneurysms.
Questions
Correct Answer is A
Explanation
A) Correct - Monitoring for signs of stroke is the priority during the immediate postoperative period for a client who underwent carotid artery endarterectomy. The procedure involves removing plaque buildup from the carotid artery, which can potentially dislodge and cause a stroke.
B) Incorrect - Assessing the surgical incision for bleeding is important, but it is not the priority when compared to monitoring for signs of stroke after a carotid endarterectomy.
C) Incorrect - Administering pain medications is essential for the client's comfort, but it is not the priority during the immediate postoperative period when there is a higher risk of stroke.
D) Incorrect - Encouraging coughing and deep breathing is a standard postoperative nursing intervention, but it is not the priority in this situation. The focus should be on monitoring for stroke symptoms.
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