The nurse is caring for a client diagnosed with an abdominal aortic aneurysm (AAA). Which of the client's vital signs will be a priority for the nurse to monitor?
Core temperature
Blood pressure
Pulse rate
Respiratory rate
The Correct Answer is B
Choice A Reason:
Core temperature is important to monitor in many clinical situations, but it is not the primary concern for a client with an abdominal aortic aneurysm. While fever can indicate infection, which is a potential complication, it is not directly related to the immediate risks associated with AAA.
Choice B Reason:
Blood pressure is the most critical vital sign to monitor in a client with an abdominal aortic aneurysm. Elevated blood pressure can increase the risk of aneurysm rupture, which is a life-threatening emergency. Maintaining blood pressure within a safe range is essential to prevent complications and ensure the stability of the aneurysm.
Choice C Reason:
Pulse rate is also important to monitor, but it is not as directly indicative of the risk of aneurysm rupture as blood pressure. While changes in pulse rate can signal cardiovascular stress or other issues, blood pressure provides more direct information about the forces acting on the aneurysm.
Choice D Reason:
Respiratory rate is a vital sign that can indicate respiratory distress or other systemic issues, but it is not the primary concern in the context of an abdominal aortic aneurysm. Blood pressure remains the most critical parameter to monitor to prevent rupture and manage the condition effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Fluid imbalance is a significant concern in burn patients due to the loss of fluids through damaged skin. This can lead to hypovolemic shock if not managed properly. However, while fluid resuscitation is crucial, it is not the immediate priority over airway management in the case of burns to the head and neck. Ensuring the airway is clear and unobstructed takes precedence because airway compromise can lead to rapid deterioration and death.
Choice B Reason:
Airway obstruction is the most critical risk in patients with extensive burns to the head and neck. Burns in these areas can cause swelling, leading to airway compromise. Inhalation injuries from smoke or hot gases can also cause airway edema and respiratory distress. Immediate assessment and intervention to secure the airway are paramount to prevent hypoxia and ensure the patient can breathe adequately. This is why airway management is the top priority in such cases.
Choice C Reason:
Infection is a major risk for burn patients due to the loss of the skin barrier, which normally protects against pathogens. Burn wounds are highly susceptible to bacterial colonization and infection, which can lead to sepsis if not properly managed. While infection control is vital, it is not the immediate priority over securing the airway in the acute phase of burn management. Once the airway is secured, infection prevention and control measures can be implemented.
Correct Answer is ["20.46"]
Explanation
Step 1: Convert the client's weight from pounds to kilograms.
150 pounds ÷ 2.2 = 68.18 kg
Result at each step = 68.18 kg
Step 2: Calculate the dose in mcg/min.
3 mcg/kg/min × 68.18 kg = 204.54 mcg/min
Result at each step = 204.54 mcg/min
Step 3: Convert the dose from mcg to mg.
204.54 mcg ÷ 1000 = 0.20454 mg/min
Result at each step = 0.20454 mg/min
Step 4: Calculate the infusion rate in mL/min.
0.20454 mg/min ÷ 600 mg × 1000 mL = 0.341 mL/min
Result at each step = 0.341 mL/min
Step 5: Convert the infusion rate to mL/hour.
0.341 mL/min × 60 min/hour = 20.46 mL/hour
Result at each step = 20.46 mL/hour
So, the infusion rate is 20.46 mL/hour.
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