A nurse is caring for a client with a suspected aneurysm. Which of the following assessments should the nurse prioritize to monitor for potential rupture?
Pain level assessment
Blood pressure measurement
Respiratory rate evaluation
Urinary output monitoring
The Correct Answer is A
A) Correct - Pain level assessment is essential in monitoring for aneurysm rupture because sudden, severe, and persistent pain is a common manifestation. It could indicate that the aneurysm is leaking or has ruptured, requiring immediate medical attention.
B) Incorrect - While blood pressure measurement is important in managing aneurysm, it may not be the best indicator of an imminent rupture. Some aneurysms are asymptomatic until they rupture.
C) Incorrect - Respiratory rate evaluation is not a primary assessment for aneurysm rupture. Although respiratory distress may occur due to pain or compromised blood flow after rupture, it is not the initial priority.
D) Incorrect - While monitoring urinary output is important in various clinical settings, it is not a priority assessment for aneurysm rupture. There are more specific symptoms related to aneurysm rupture that the nurse should focus on.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect - Arterial blood gas levels are important for assessing respiratory status but are not specifically related to monitoring the success of peripheral artery bypass surgery.
B) Incorrect - Central venous pressure (CVP) monitoring is typically not necessary for clients who have undergone peripheral artery bypass surgery. It is used to assess fluid volume status in critical care settings.
C) Correct - Assessing peripheral pulses distal to the surgical site is crucial in monitoring the success of peripheral artery bypass surgery. Improved blood flow should result in stronger and more palpable pulses in the affected limb.
D) Incorrect - Monitoring abdominal girth is not directly related to peripheral artery bypass surgery. It may be relevant for assessing other conditions, but it does not specifically monitor the success of the procedure.
Correct Answer is B
Explanation
A) Incorrect - Avoiding showering or bathing for 24 hours after the procedure is unnecessary. Clients can usually shower the day after the angioplasty, but should avoid soaking the insertion site in water.
B) Correct - Keeping the insertion site dry and covered with a dressing is the appropriate wound care for the first 24 hours after peripheral angioplasty. This helps prevent infection and protect the site.
C) Incorrect - Cleaning the insertion site with hydrogen peroxide daily is not recommended, as it may delay wound healing. Instead, clients should follow the healthcare provider's instructions on wound care.
D) Incorrect - Rubbing the insertion site with a washcloth during showers is not advisable, as it may irritate the area and interfere with proper wound healing. The insertion site should be gently washed without scrubbing.
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