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 C
Explanation
Choice A: Vitamin K
Vitamin K is essential for the synthesis of clotting factors and is often used to treat bleeding disorders caused by vitamin K deficiency or to reverse the effects of anticoagulants like warfarin. However, in the context of disseminated intravascular coagulation (DIC), the primary issue is not a deficiency of clotting factors but rather an overactivation of the clotting cascade leading to both clot formation and bleeding. Therefore, while vitamin K can be beneficial in certain bleeding disorders, it is not the primary treatment for DIC.
Choice B: Statin
Statins are medications used to lower cholesterol levels and reduce the risk of cardiovascular disease. They work by inhibiting the enzyme HMG-CoA reductase, which plays a crucial role in cholesterol synthesis. Statins are not used in the management of DIC as they do not address the underlying pathophysiology of the condition, which involves widespread clotting and subsequent bleeding.
Choice C: Heparin
Heparin is an anticoagulant that helps prevent the formation of new clots and the extension of existing clots. In the management of DIC, heparin can be used to interrupt the clotting process and prevent further consumption of clotting factors. This can help stabilize the patient and reduce the risk of severe bleeding. Heparin is particularly useful in cases where thrombosis is predominant. It is important to monitor the patient closely to balance the risk of bleeding with the benefits of anticoagulation.
Choice D: Metformin
Metformin is an oral hypoglycemic agent used to manage type 2 diabetes by improving insulin sensitivity and reducing glucose production in the liver. It has no role in the treatment of DIC, as it does not affect the coagulation pathways or the underlying causes of DIC.
Correct Answer is ["20"]
Explanation
Step-by-Step Calculation:
Step 1: Identify the prescribed dose.
1000 units per hour
Step 2: Identify the concentration of heparin in the IV bag.
25,000 units in 500 mL
Step 3: Calculate the concentration of heparin per mL.
25,000 units ÷ 500 mL = 50 units/mL
Result = 50 units/mL
Step 4: Calculate the IV pump rate in mL/hr.
1000 units per hour ÷ 50 units/mL = 20 mL/hr
Result = 20 mL/hr
Final Result:
The IV pump should be set to 20 mL/hr.
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