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
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.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. "They will circulate my blood on a machine during the surgery.": This is correct information regarding the use of a heart-lung machine during CABG.
B. "I will need to take an aspirin every day after the surgery to keep the graft open.": Daily aspirin therapy is standard to prevent graft occlusion, indicating correct understanding.
C. "They will use an artery near my heart to go around the area that is blocked.": This accurately describes using the internal mammary artery for the bypass, showing correct knowledge.
D. "I will have small incisions in my leg where they will remove the vein.": This indicates confusion, as the internal mammary artery, not leg veins, is used in this type of CABG.
Correct Answer is A
Explanation
A. To calculate the infusion rate: 125 mg in 100 ml = 1.25 mg/ml. Required: 10 mg/hr ÷ 1.25 mg/ml = 8 ml/hr.
B. To calculate the infusion rate: 125 mg in 100 ml = 1.25 mg/ml. Required: 10 mg/hr ÷ 1.25 mg/ml = 8 ml/hr.
C. To calculate the infusion rate: 125 mg in 100 ml = 1.25 mg/ml. Required: 10 mg/hr ÷ 1.25 mg/ml = 8 ml/hr.
D. To calculate the infusion rate: 125 mg in 100 ml = 1.25 mg/ml. Required: 10 mg/hr ÷ 1.25 mg/ml = 8 ml/hr.
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