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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Free Nursing Study Resources

Correct Answer is ["937.5"]

Explanation

Calculate the fluid volume to be administered in the remaining 16 hours:

Total fluid volume - Fluid administered in the first 8 hours = Remaining fluid volume

30,000 mL - (1875 mL/hr * 8 hr) = 15,000 mL

Calculate the infusion rate for the remaining 16 hours:

Remaining fluid volume / Remaining time = Infusion rate

15,000 mL / 16 hr = 937.5 mL/hr

Therefore, the nurse should infuse the IV fluids at a rate of 937.5 mL/hr after the first 8 hours.

A. Apply a paper bag over the clients nose and mouth. B. Administer 50 mL of 20% glucose and 20 units of regular insulin. C. Administer 50 mL of sodium bicarbonate intravenously. D. Apply oxygen by mask or nasal cannula.

Correct Answer is D

Explanation

A. Appling a paper bag over the client's nose and mouth is used for hyperventilation or respiratory alkalosis, not for respiratory acidosis. In this case, it would worsen the client’s condition by increasing CO2 retention.

B. Administering 50 mL of 20% glucose and 20 units of regular insulin is appropriate for hyperkalemia or diabetic ketoacidosis, not respiratory acidosis following a seizure.

C. Administering 50 mL of sodium bicarbonate intravenously is used for severe metabolic acidosis. This client’s acidosis is primarily respiratory in origin, making this choice inappropriate.

D. Applying oxygen by mask or nasal cannula helps correct the low oxygen levels and supports respiration post-seizure.

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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

Correct Answer is ["937.5"]

Explanation

A client has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas results: pH 7.12, HCO3 22 mEq/L, PaCO2 55 mmHg, PaO2 60 mmHg. Which intervention is the most appropriate?

Correct Answer is D

Explanation

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