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: Amylase is elevated in acute pancreatitis due to pancreatic acinar cell damage, releasing digestive enzymes. Monitoring serum amylase confirms the diagnosis and tracks disease severity, as levels correlate with inflammation. This is a key marker, essential for assessing pancreatic injury in sudden abdominal pain.

Choice B reason: Glucose levels rise in pancreatitis due to impaired insulin release from damaged pancreatic beta cells. Hyperglycemia indicates disease severity and complications like pancreatic necrosis. Monitoring glucose ensures timely management of metabolic disturbances, critical in acute pancreatitis with sudden pain and systemic effects.

Choice C reason: Serum triglycerides are monitored, as hypertriglyceridemia is a common cause of acute pancreatitis. Elevated levels exacerbate pancreatic inflammation by inducing lipotoxicity. Tracking triglycerides guides treatment, like lipid-lowering therapy, and assesses risk of recurrent attacks, making it essential in suspected pancreatitis cases.

Choice D reason: Calcium levels drop in acute pancreatitis due to fat necrosis binding calcium (saponification). Hypocalcemia signals severe disease and complications like tetany. Monitoring calcium ensures timely supplementation, preventing life-threatening outcomes, and is critical for managing systemic effects in acute pancreatic inflammation.

Choice E reason: White blood cell count rises in pancreatitis due to systemic inflammatory response. Leukocytosis indicates infection or severe inflammation, guiding antibiotic or supportive care needs. Monitoring this assesses disease progression and complications, making it vital for managing suspected acute pancreatitis with abdominal pain.

A. Platelets B. Albumin C. Glucose D. Serum electrolytes

Correct Answer is C

Explanation

Choice A reason: Platelets are unaffected by hydrocortisone in Addison’s disease. Hydrocortisone replaces cortisol, regulating metabolism, not coagulation. Platelet monitoring is relevant for bleeding disorders, not adrenal insufficiency, making this value less critical than glucose, which is directly impacted by cortisol’s gluconeogenic effects.

Choice B reason: Albumin reflects nutritional status but is not directly altered by hydrocortisone. Addison’s disease and hydrocortisone affect glucose and electrolytes via cortisol’s metabolic roles, not protein synthesis. Albumin is secondary, as glucose monitoring addresses immediate metabolic complications of corticosteroid therapy.

Choice C reason: Glucose is critical to monitor, as hydrocortisone increases gluconeogenesis and insulin resistance in Addison’s disease, risking hyperglycemia. Elevated glucose can cause osmotic diuresis or ketoacidosis, requiring dose adjustments or insulin therapy, making this the most important value to ensure safe corticosteroid management.

Choice D reason: Serum electrolytes, like sodium and potassium, are affected by Addison’s, but hydrocortisone primarily corrects hyponatremia and hyperkalemia. Glucose is more critical, as hydrocortisone’s glucocorticoid effects directly raise blood sugar, posing immediate metabolic risks, making this value secondary to glucose monitoring.

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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

A client is admitted with sudden abdominal pain and possible acute pancreatitis. Which serum laboratory test result(s) should the nurse monitor? (Select all that apply)

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

Explanation

A client with Addison’s disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?

Correct Answer is C

Explanation

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