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

Answer and Explanation

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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Correct Answer is D

Explanation

A. A pressure dressing is already in place following the procedure, and additional dressing is not the priority. Instead, monitoring the TR band for bleeding or complications is essential.
B. Having the client flex and extend the right wrist is not recommended immediately after a radial artery catheterization, as movement can increase the risk of bleeding.
C. Oxygen therapy is not routinely required unless the client has hypoxia or respiratory distress.
D. Assessing the trans-radial (TR) band is the priority to ensure proper hemostasis at the puncture site, monitor for bleeding, and check distal circulation to the hand.

A. Hypernatremia B. Hypocalcemia C. Hypokalemia D. Hyperkalemia

Correct Answer is C

Explanation

A. Hypernatremia is incorrect. Furosemide can cause hyponatremia rather than hypernatremia due to increased sodium excretion.
B. Hypocalcemia is incorrect. While loop diuretics can cause some calcium loss, hypocalcemia is less common than hypokalemia.
C. Hypokalemia is correct. Furosemide is a loop diuretic that increases potassium excretion, leading to a risk of hypokalemia, which can cause muscle weakness, arrhythmias, and other complications.
D. Hyperkalemia is incorrect. Furosemide promotes potassium excretion, making hyperkalemia unlikely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client post-cardiac catheterization with a right radial artery puncture site. The nurse performs which priority assessment on arrival to the unit?

Correct Answer is D

Explanation

A nurse is caring for a client with heart failure who takes furosemide (Lasix) 20 mg daily at home and is receiving 40 mg of furosemide (Lasix) IV daily in the hospital. The nurse is aware that this patient is at risk for which electrolyte imbalance?

Correct Answer is C

Explanation

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