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 C

Explanation

Choice A reason: Lying down after meals worsens gastroesophageal reflux, as gravity promotes acid backflow into the esophagus. Elevation prevents reflux, and this instruction contradicts evidence-based management, increasing symptoms like heartburn, making it harmful for the client’s condition.

Choice B reason: Using antacids as a last resort is incorrect, as they neutralize acid, relieving reflux symptoms. Antacids are first-line for mild cases, and delaying use may worsen discomfort, making this instruction contrary to standard management of gastroesophageal reflux.

Choice C reason: Elevating the head of the bed on blocks prevents acid reflux by using gravity to keep stomach contents down during sleep. This reduces esophageal irritation, a key strategy in gastroesophageal reflux management, making it the most effective discharge instruction for symptom control.

Choice D reason: Avoiding high-fiber foods is incorrect, as fiber aids digestion and may reduce reflux by promoting gastric emptying. Low-fiber diets can worsen constipation, increasing intra-abdominal pressure, making this instruction detrimental to managing gastroesophageal reflux effectively.

A. The stoma mucosa is purple in color B. The fecal matter is brown and has a solid consistency C. The stoma has streaks of bright red blood D. There are no bowel sounds in the left lower quadrant

Correct Answer is A

Explanation

Choice A reason: A purple stoma mucosa indicates ischemia or necrosis, a surgical emergency post-colostomy. Poor blood supply risks stoma failure, infection, or perforation, requiring immediate surgical evaluation. This finding is critical, as it threatens the colostomy’s viability, making it the priority to report.

Choice B reason: Brown, solid fecal matter is normal 24 hours post-colostomy, indicating bowel function. This does not suggest complications like ischemia or obstruction, requiring no immediate reporting, as it aligns with expected postoperative outcomes, making this finding benign.

Choice C reason: Streaks of bright red blood from the stoma suggest minor trauma or irritation, common post-colostomy. This is less urgent than purple mucosa, which indicates ischemia, a life-threatening issue, making bleeding a secondary concern requiring monitoring but not immediate surgical intervention.

Choice D reason: Absent bowel sounds in the left lower quadrant are expected post-bowel surgery due to ileus. This is less urgent than purple stoma mucosa, which signals necrosis, requiring immediate action, making bowel sounds a normal postoperative finding not warranting urgent reporting.

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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

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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