A nurse is caring for a client post-endarterectomy for carotid artery stenosis. What is the priority nursing intervention during the immediate postoperative period?
Monitoring for signs of stroke
Assessing the surgical incision for bleeding
Administering pain medications
Encouraging coughing and deep breathing
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect - Limiting daily water intake is not a lifestyle modification that directly impacts aneurysm prevention. Adequate hydration is generally encouraged for overall health.
B) Correct - Engaging in regular aerobic exercise is a lifestyle modification that can help prevent aneurysms and promote cardiovascular health. Exercise improves blood circulation and reduces the risk of various vascular disorders.
C) Incorrect - Consuming a high-fat diet is not recommended for aneurysm prevention. High-fat diets can contribute to atherosclerosis and other cardiovascular issues.
D) Incorrect - Smoking, even in small amounts, is a significant risk factor for aneurysms. Any amount of smoking should be strongly discouraged for individuals interested in preventing aneurysms and peripheral vascular disorders.
Questions
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.
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