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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Incorrect - While surgical repair is an option for larger or symptomatic AAAs, it is not the only treatment option for small, asymptomatic AAAs.

B) Correct - For small asymptomatic AAAs, close monitoring of the aneurysm size and growth is a common approach. The size and rate of growth will determine the appropriate treatment plan.

C) Incorrect - Blood-thinning medications are not the standard treatment for small asymptomatic AAAs. These medications are generally used for other cardiovascular conditions.

D) Incorrect - Endovascular repair may be an option for some AAAs, but it is not the best treatment for all cases, especially small, asymptomatic ones. The appropriate treatment plan will depend on the client's specific circumstances.

A. Apply a heating pad to the affected leg B. Elevate the leg above heart level C. Rest and avoid moving the leg D. Perform gentle leg exercises

Correct Answer is C

Explanation

A. Applying a heating pad is not appropriate because clients with PAD have reduced circulation, increasing the risk of burns due to impaired sensation.
B. Elevating the leg above heart level can further reduce arterial blood flow, worsening ischemia.
C. Resting and avoiding movement is the best action, as sudden severe pain, numbness, and coolness suggest acute arterial occlusion, a medical emergency requiring immediate evaluation to prevent limb loss.
D. Performing gentle leg exercises is not advisable, as movement could further compromise circulation in an acutely ischemic limb.

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A nurse is caring for a client post-endarterectomy for carotid artery stenosis. What is the priority nursing intervention during the immediate postoperative period?

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Naxlex Comprehensive Predictor Exams

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