The new graduate nurse is assessing a client with an unrepaired abdominal aortic aneurysm. What assessment technique requires further education by the supervising nurse?

Measurement of abdominal girth

Auscultation of any area in the abdomen

Palpation of the abdominal midline area

Observation of abdominal wall movement

Answer and Explanation

The Correct Answer is C

A. Measuring abdominal girth can help monitor the aneurysm.

B. Auscultation is safe and may reveal bruits associated with aneurysms.

C. Palpation of the abdominal midline area is dangerous and can risk rupturing the aneurysm, requiring further education.

D. Observation is non-invasive and safe.

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Correct Answer is D

Explanation

A. Testing the equipment with a smaller shock is unnecessary when preparing to defibrillate in an emergency.

B. Epinephrine is used in cases of cardiac arrest with no pulse, particularly in asystole or pulseless electrical activity (PEA), not immediately before defibrillation in ventricular fibrillation.

C. Synchronous mode is used for cardioversion, not for defibrillation. Defibrillation should be delivered in unsynchronized mode.

D. Before delivering a shock, it is essential to ensure that everyone, including the nurse, is clear of the client and any conductive surfaces like the bed. This prevents injury from the electrical shock.

A. An 80-year-old with chronic obstructive pulmonary disease. B. A 78-year-old who had a carotid endarterectomy. C. A 45-year-old who takes an aspirin daily. D. A 50-year-old who is post coronary artery bypass graft surgery.

Correct Answer is A

Explanation

A. Atrial fibrillation (AF) is more common in older adults, particularly those with underlying conditions like chronic obstructive pulmonary disease (COPD). COPD can lead to structural changes in the heart, increasing the risk of AF. The elderly are particularly vulnerable due to age-related heart changes and comorbidities such as lung disease.

B. While carotid endarterectomy is a surgical procedure that can be related to stroke prevention, it is not directly associated with a higher risk of AF compared to COPD.

C. Aspirin is used for its antiplatelet effects, not directly related to the risk of AF.

D. Post coronary artery bypass graft (CABG) surgery increases the risk for arrhythmias, but it is less directly linked to AF than conditions like COPD in an older adult.

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The new graduate nurse is assessing a client with an unrepaired abdominal aortic aneurysm. What assessment technique requires further education by the supervising nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client?

Correct Answer is D

Explanation

A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation?

Correct Answer is A

Explanation

A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure?

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