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. Drinking water is not likely to alleviate the headache caused by the nitrate.

B. Holding the next dose is not necessary unless the headache becomes severe or is associated with other symptoms.

C. Initiating oxygen therapy is unnecessary for a headache caused by nitrate use.

D. A headache is a common side effect of nitrate administration due to the vasodilation effect. Administering PRN acetaminophen can help relieve the headache.

A. Increase IV fluid infusion per protocol. B. Lower the head of the clients bed in Trendelenburg position C. Document CVP and continue to monitor. D. Administer IV diuretic medications.

Correct Answer is D

Explanation

A. Increasing IV fluids would exacerbate the client's fluid overload and worsen heart failure symptoms.

B. Trendelenburg positioning is typically used for shock management, but this client’s fluid overload needs to be addressed first.

C. Monitoring is important but does not address the immediate need to manage fluid overload.

D. The client's elevated CVP, PAWP, and BNP levels indicate fluid overload and heart failure with reduced ejection fraction. The priority is to reduce fluid overload by administering IV diuretics, which will help reduce the pressure in the heart and lungs, improving oxygenation and decreasing the risk of pulmonary edema.

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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 assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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