A nurse is caring for a client with a history of an abdominal aortic aneurysm (AAA). Which of the following assessments should be the nurse's priority for a client with an abdominal aortic aneurysm?
Deep palpation of the abdomen
Review of chest x-ray
Assessing the client’s pain
Assessment of blood pressure
The Correct Answer is D
A. Deep palpation of the abdomen is contraindicated in clients with an AAA, as it may cause rupture.
B. A chest X-ray may detect an aneurysm, but it is not the priority assessment.
C. Pain assessment is important, as sudden severe pain could indicate rupture, but it is not the first priority.
D. Blood pressure assessment is the priority, as hypertension can increase the risk of aneurysm rupture. Strict BP control is critical to preventing complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While potassium is typically diluted in IV fluids, the concentration and infusion rate must be clarified before administration. A standard dilution is 10 mEq in 100 mL or 40 mEq in 1L, but this must be verified.
B. Calling the physician for clarification is the safest step. IV potassium should never be given undiluted or as an IV push due to the risk of fatal cardiac arrhythmias.
C. IV push potassium is never appropriate as it can cause cardiac arrest.
D. Administering the undiluted 20 mEq/mL solution is dangerous and requires proper dilution before administration.
Correct Answer is A
Explanation
A. Dyspnea is the priority finding as it may indicate heart failure or pulmonary embolism, both of which are life-threatening complications of infective endocarditis.
B. Anorexia is a common symptom but is not an immediate threat to the client's condition.
C. Malaise is a general symptom of infection but does not require urgent intervention.
D. Fever is a hallmark sign of infection but is not as critical as assessing for complications such as heart failure or embolic events.
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