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.
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Related Questions
Correct Answer is B
Explanation
A. A blood pressure of 110/70 and heart rate of 90 is within normal limits and does not indicate an immediate complication.
B. Swelling at the insertion site and a cool extremity suggest arterial occlusion or hematoma formation, which is a serious complication requiring immediate intervention. This may indicate impaired blood flow to the limb.
C. Oozing blood from the site may require monitoring and pressure application but is not as concerning as signs of arterial compromise.
D. Not voiding post-procedure can be due to bedrest or IV contrast, but it is not an urgent concern.
Correct Answer is B
Explanation
A. Pruritus is not a common side effect of heparin therapy. While allergic reactions can occur, they are not the primary concern.
B. Petechiae are a sign of bleeding, which is a major side effect of heparin therapy. Heparin increases the risk of bleeding by inhibiting clot formation, and petechiae may indicate early signs of hemorrhage.
C. Confusion is not directly associated with heparin therapy unless it results from severe bleeding leading to hypoxia or shock.
D. A slowing pulse rate is not a known adverse effect of heparin. Instead, monitoring for signs of bleeding, such as bruising, hematuria, and petechiae, is the priority.
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