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

Elevate extremities on pillows.

Evaluate edema for pitting.

Wrap the feet with warmed blankets.

Assess pulses with a vascular Doppler

Answer and Explanation

The Correct Answer is D

A. Elevate extremities on pillows:
While elevation can be beneficial for reducing dependent edema, the priority is to assess the pulses first to determine the adequacy of peripheral perfusion.

B. Evaluate edema for pitting:
Assessing edema for pitting is important for gathering additional information, but it is not the initial action in this scenario. Assessing pulses is more critical to evaluate perfusion.

C. Wrap the feet with warmed blankets:
Warming the feet with blankets may be appropriate in some situations, but it is not the priority when the client is exhibiting edema and non-palpable pedal pulses. The primary concern is assessing perfusion.

D. Assess pulses with a vascular Doppler:
This is the correct action. The non-palpable pedal pulses are concerning and require immediate assessment to determine the status of peripheral perfusion. Using a vascular Doppler will help the nurse assess the presence or absence of blood flow in the lower extremities.

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Correct Answer is B

Explanation

A. Keep the room at a comfortable temperature:
While maintaining a comfortable room temperature is important for the overall well-being of the client, it is not the most essential intervention during a seizure. The priority during a seizure is to ensure the client's safety, particularly focusing on airway management.

B. Ensure oral suction is available:
This is the most essential intervention. During a seizure, the client may produce excessive saliva, and having oral suction readily available helps prevent airway obstruction and ensures a clear airway. It is crucial for the safety and well-being of the client.

C. Provide frequent mouth care:
Mouth care is important for the overall hygiene of the unconscious client, but it may not be the most immediate priority during a seizure. The focus during a seizure is on preventing complications such as aspiration or airway obstruction.

D. Maintain the client in a semi-Fowler's position:
Positioning is important for the comfort and safety of the unconscious client, but maintaining a semi-Fowler's position may not be the primary concern during an active seizure. The immediate focus is on airway management and preventing injury.

A. Eat a diet high in carotene. B. Wear prescription glasses. C. Avoid frequent eye pressure measurements. D. Maintain prescribed eye drop regimen

Correct Answer is D

Explanation

A. Eat a diet high in carotene:
While a healthy diet is important for overall well-being, there is no evidence to suggest that a diet high in carotene specifically prevents or treats glaucoma. The focus in glaucoma management is on intraocular pressure control.

B. Wear prescription glasses:
Prescription glasses may be beneficial for addressing refractive errors, but they do not specifically address the management of glaucoma. The client's concern about driving through a tunnel is more likely related to changes in peripheral vision associated with glaucoma.

C. Avoid frequent eye pressure measurements:
This is not the most important instruction. Monitoring intraocular pressure is a crucial aspect of glaucoma management, and the frequency of measurements is determined by the healthcare provider. Regular monitoring helps assess the effectiveness of treatment and disease progression.

D. Maintain the prescribed eye drop regimen:
This is the correct answer. The most important instruction for the client is to adhere to the prescribed eye drop regimen. Medications, often in the form of eye drops, are commonly used to lower intraocular pressure and manage glaucoma. Consistent use of prescribed medications is critical for controlling the condition and preventing further vision loss.

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Four days following an abdominal aortic aneurysm 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

When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

Correct Answer is B

Explanation

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

Correct Answer is D

Explanation

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

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