The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
White blood cell count and pulse rate.
Hematocrit and blood pressure.
Calcium level and skin condition.
Serum amylase and level of consciousness.
The Correct Answer is B
Choice A reason: White blood cell count and pulse rate are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. White blood cell count is a measure of the immune system activity, and it may be elevated in cases of infection or inflammation, but it is not specific to AAA. Pulse rate is a measure of the heart rate, and it may be increased in cases of anxiety, pain, or shock, but it is not indicative of AAA.
Choice B reason: Hematocrit and blood pressure are the most important information about the client that the nurse should tell the healthcare provider, because they are directly related to the AAA and the low back pain. Hematocrit is a measure of the percentage of red blood cells in the blood, and it may be decreased in cases of bleeding or anemia, which can occur if the AAA ruptures or leaks. Blood pressure is a measure of the force of the blood against the walls of the arteries, and it may be increased in cases of hypertension or stress, which can worsen the AAA or cause it to rupture. The nurse should monitor the client's hematocrit and blood pressure closely and report any changes to the healthcare provider.
Choice C reason: Calcium level and skin condition are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Calcium level is a measure of the amount of calcium in the blood, and it may be abnormal in cases of bone disorders, kidney disorders, or parathyroid disorders, but it is not relevant to AAA. Skin condition is a general term that can describe the appearance, texture, color, or temperature of the skin, and it may be altered in cases of infection, allergy, or injury, but it is not specific to AAA.
Choice D reason: Serum amylase and level of consciousness are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Serum amylase is a measure of the amount of amylase, an enzyme that digests starch, in the blood, and it may be elevated in cases of pancreatitis, gallstones, or intestinal obstruction, but it is not associated with AAA. Level of consciousness is a measure of the client's mental status, alertness, and responsiveness, and it may be impaired in cases of brain injury, stroke, or coma, but it is not indicative of AAA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Beginning a weight loss program can help reduce the severity of OSA, which is a condition that causes repeated episodes of breathing cessation during sleep due to upper airway obstruction. Excess weight can contribute to OSA by increasing the fat deposits around the neck and throat, which can narrow the airway and make it more prone to collapse. Losing weight can help improve the airflow and reduce the need for CPAP therapy.
Choice B reason: Drinking 1 to 2 glasses of wine at bedtime can worsen OSA, which is a condition that requires adequate oxygenation and ventilation during sleep. Alcohol can relax the muscles of the throat and tongue, which can increase the risk of airway obstruction and apnea. Alcohol can also disrupt the sleep cycle and quality, which can affect the overall health and well-being of the client.
Choice C reason: Taking sedatives prior to sleep can also worsen OSA, which is a condition that requires alertness and arousal during sleep to resume breathing after an apneic episode. Sedatives can depress the central nervous system and the respiratory drive, which can reduce the responsiveness and the ability to overcome the airway obstruction. Sedatives can also have adverse effects, such as drowsiness, confusion, and dependency.
Choice D reason: Sleeping with the head of the bed flat can also worsen OSA, which is a condition that requires optimal positioning and alignment during sleep to prevent the airway obstruction. Sleeping with the head of the bed flat can cause the tongue and the soft palate to fall back and block the airway, especially when lying on the back. Sleeping with the head of the bed elevated can help open the airway and reduce the snoring and the apnea.
Correct Answer is A
Explanation
Choice A reason: Isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action that the nurse should take, because it can prevent the transmission of COVID-19, which is a highly contagious respiratory disease caused by a novel coronavirus. The client has symptoms that are consistent with COVID-19, such as conjunctivitis, loss of taste and smell, and recent travel history, and the nasal swab test can confirm the diagnosis. The nurse should follow the infection control precautions, such as wearing a mask, gloves, gown, and eye protection, and place the client in a private room with negative pressure ventilation, if available.
Choice B reason: Reporting the COVID-19 result to the local health department according to CDC guidelines is an important action that the nurse should take, but it is not the most important one. Reporting the COVID-19 result can help the public health authorities to monitor the epidemiology, track the contacts, and implement the interventions to control the outbreak. However, reporting the result can only be done after the test is completed and confirmed, which may take some time. The nurse should prioritize the immediate isolation of the client to prevent the spread of the virus.
Choice C reason: Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is an important action that the nurse should take, but it is not the most important one. Teaching the client to wear a mask, hand wash, and social distance can help the client to protect themselves and others from COVID-19, which can be transmitted through respiratory droplets, contact, and aerosols. However, teaching the client these measures can only be effective if the client follows them and adheres to the isolation guidelines. The nurse should first isolate the client and then provide the education.
Choice D reason: Explaining to the client to inform others that they may have been potentially exposed in the last 14 days is an important action that the nurse should take, but it is not the most important one. Explaining to the client to inform others that they may have been potentially exposed in the last 14 days can help the client to notify their close contacts, such as family, friends, co-workers, and travel companions, who may have been at risk of COVID-19 infection. However, explaining to the client this information can only be useful if the client cooperates and remembers their contacts. The nurse should first isolate the client and then assist the client with the contact tracing.
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