A nurse is caring for a client with an abdominal aortic aneurysm. Which of the following nursing interventions is anticipated for this client?

Hold administration of analgesics

Keep blood pressure elevated to promote perfusion

Administer antibiotics as prescribed

Keep blood pressure within ordered parameters

Answer and Explanation

The Correct Answer is D

A. Analgesics are important to manage pain and reduce stress, which can help prevent aneurysm rupture.
B. Keeping blood pressure elevated increases the risk of aneurysm rupture and is not appropriate.
C. Antibiotics are not routinely indicated unless there is an infection.
D. Controlling blood pressure reduces stress on the aneurysm wall, minimizing the risk of rupture.

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Correct Answer is A

Explanation

A. Osmotic diuretics like mannitol draw fluid out of brain tissue into the bloodstream, reducing cerebral edema and lowering intracranial pressure.
B. Increasing cell size would worsen cerebral edema and is not the goal of treatment.
C. Osmotic diuretics do not provide fluid hydration; they promote fluid removal.
D. Increasing edema in the brain is harmful and contrary to the purpose of the medication.

A nurse is caring for a client who has a pneumothorax.

Exhibits

A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax?

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A. Obtain ABGS. B. Prepare for insertion of a chest tube. C. Obtain intravenous access. D. Computed tomography (CT) of the chest E. Pulmonary Function Tests (PFTS) F. Thoracentesis

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

Anticipated:

Obtain ABGs: This is anticipated because arterial blood gases help evaluate oxygenation and acid-base status. Since the client has a low O₂ saturation (85%) and is showing signs of respiratory distress, ABGs are essential for guiding oxygen therapy and further interventions.

Prepare for insertion of a chest tube: A chest tube is the primary treatment for a pneumothorax. It allows air to escape the pleural space and re-expand the lung. The client's absent breath sounds and labored breathing indicate a significant air accumulation that needs urgent management.

Obtain intravenous access: IV access is essential to administer fluids, analgesics, or emergency medications, especially in a hypotensive client (BP 92/64 mm Hg) showing signs of shock and respiratory compromise.

Computed tomography (CT) of the chest: A CT scan may be ordered to assess the extent of lung injury or to evaluate for concurrent thoracic trauma. It provides more detailed imaging than a chest x-ray and is appropriate once the client is stabilized.

Non-essential:

Thoracentesis: Thoracentesis is used to remove fluid from the pleural space, such as in pleural effusion, not air, as in pneumothorax. Performing thoracentesis in this case could worsen the condition or lead to further complications.

Contraindicated:

Pulmonary Function Tests (PFTs): PFTs are not appropriate in this scenario. They require the client to perform forced breathing maneuvers, which are unsafe and impractical for someone in acute respiratory distress with a pneumothorax.

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A nurse is caring for a client with an abdominal aortic aneurysm. Which of the following nursing interventions is anticipated for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse Identify as the purpose of the medication?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

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