Four days following an abdominal aortic aneurysm (AAA) repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Elevate both lower extremities

Administer a PRN diuretic as prescribed

Evaluate edema of the lower extremities

Assess distal pulses with a Doppler device

Answer and Explanation

The Correct Answer is D

Choice A reason: Elevating extremities reduces edema but does not address absent pulses, indicating possible arterial occlusion post-AAA repair. Doppler assessment confirms pulse status, identifying critical ischemia, and elevation is secondary, as it does not diagnose the underlying vascular compromise requiring urgent intervention.

Choice B reason: Administering a diuretic treats edema but ignores absent pulses, a sign of arterial compromise post-AAA repair. Doppler assessment identifies ischemia, and diuretics may worsen hypovolemia, risking graft failure, making this action less urgent than confirming vascular patency.

Choice C reason: Evaluating edema provides data but does not prioritize absent pulses, suggesting arterial occlusion post-AAA repair. Doppler assessment directly confirms pulse status, guiding urgent vascular intervention, and edema evaluation is secondary, as pulses indicate a more immediate threat to limb viability.

Choice D reason: Assessing distal pulses with Doppler is critical first, as absent pulses post-AAA repair suggest graft thrombosis or arterial occlusion, risking limb ischemia. Doppler confirms pulse presence, guiding urgent surgical consultation, making it the priority to prevent irreversible tissue damage or amputation.

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Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: Contact precautions prevent MRSA spread, as it transmits via direct contact or contaminated surfaces. Isolation with gowns and gloves reduces nosocomial infection risk, critical for protecting staff and patients, making this a key intervention in the plan of care for suspected MRSA.

Choice B reason: Administering vancomycin is essential, as it treats MRSA, a resistant bacterium requiring specific antibiotics. Vancomycin targets cell wall synthesis, effective against MRSA, and prompt administration prevents systemic spread, making it a critical intervention for confirmed or suspected infections.

Choice C reason: Obtaining a wound culture confirms MRSA diagnosis by identifying the pathogen and its antibiotic sensitivity. This guides targeted therapy, ensuring effective treatment and preventing resistance, making it a vital step in managing suspected MRSA infections in the care plan.

Choice D reason: Monitoring white blood cell count tracks infection severity, as leukocytosis indicates MRSA’s systemic inflammatory response. This helps assess treatment response and complications, making it an important intervention to evaluate the client’s condition and guide ongoing management of the infection.

Choice E reason: Ensuring hand hygiene compliance prevents MRSA transmission, a highly contagious pathogen spread via contact. Rigorous handwashing reduces cross-contamination, protecting the client, staff, and others, making it an essential intervention in the care plan for infection control.

A. Discuss with your healthcare provider which medications to take before surgery B. Bring copies of all your prescription records C. Bring all of your medication containers to your preoperative appointment D. Obtain a copy of your medication records from your healthcare provider (HCP)

Correct Answer is C

Explanation

Choice A reason: Discussing medications with the provider is necessary but vague and not actionable during the call. Bringing medication containers provides concrete data, ensuring accurate preoperative reconciliation, reducing risks like drug interactions, making this response less effective for immediate medication assessment.

Choice B reason: Bringing prescription records is helpful but less direct than medication containers, which show current drugs, doses, and adherence. Records may be incomplete, and containers allow visual verification, ensuring accurate perioperative planning, making this response secondary to physical medication review.

Choice C reason: Bringing medication containers is the best response, as it allows the nurse to verify all current medications, doses, and schedules. This ensures accurate preoperative reconciliation, preventing drug interactions or withdrawal, critical for safe anesthesia and surgery, making it the priority instruction.

Choice D reason: Obtaining records from the provider is time-consuming and may delay preoperative planning. Medication containers provide immediate, accurate data for reconciliation, reducing risks of errors, making this response less practical than having the client bring physical containers for direct review.

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Four days following an abdominal aortic aneurysm (AAA) repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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