The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

Wrap both legs in a warming blanket

Compare ﬁndings to the preoperative assessment of the pulses

Document the ﬁndings and recheck in 15 minutes.

Notify the surgeon and anesthesiologist

Answer and Explanation

The Correct Answer is D

The nurse should prioritize notifying the surgeon and anesthesiologist as the ﬁrst action. The absent pulses, coolness, and mottled appearance of the leg indicate potential compromised blood ﬂow to the lower extremity, which could be a sign of vascular compromise or acute limb ischemia. These ﬁndings are concerning after the repair of an abdominal aortic aneurysm and require immediate medical attention.

Wrap both legs in a warming blanket: While it is important to maintain the client's body temperature, this action alone may not address the underlying issue of compromised blood ﬂow and potential limb ischemia. Notifying the surgeon and anesthesiologist is the priority to address the immediate concern.

Compare ﬁndings to the preoperative assessment of the pulses: While comparing ﬁndings to the preoperative assessment is important for evaluating the client's condition, it should not delay immediate action. The priority in this situation is to promptly notify the surgeon and anesthesiologist to address the potential vascular compromise.

Document the ﬁndings and recheck in 15 minutes: Documenting the ﬁndings is an important step in the nursing process, but it should not take precedence over immediate intervention. The concerning signs of absent pulses, coolness, and mottled appearance require urgent attention, and delaying notiﬁcation could lead to further complications.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

The nurse should teach the client that the transthoracic echocardiography is a noninvasive test and that nothing will be inserted into the client's body.

Transthoracic echocardiography is a diagnostic procedure that uses ultrasound to create images of the heart's structures and assess its function. It is a noninvasive test, meaning that it does not involve any insertion of instruments or devices into the body. Instead, a transducer is placed on the chest to obtain images of the heart.

The statement about managing pain aggressively during the procedure is not applicable to transthoracic echocardiography. It is generally a painless procedure that does not cause discomfort.

Transthoracic echocardiography primarily provides detailed images of the heart's structures and function, such as the chambers, valves, and pumping action. It does not specifically profile the heart's electrical activity, which is usually assessed using an electrocardiogram (ECG) or other specialized tests.

Regarding bed rest after the test, there is typically no need for bed rest following transthoracic echocardiography. The client can usually resume normal activities immediately after the procedure. However, the nurse should provide specific instructions based on the client's condition and any additional tests or interventions planned.

A. Blood glucose 90 mg/dL B. Pain level of 10 out of 10 C. Temperature 101.9 F D. Hemoglobin: 7g/dl E. Cocaine abuse

Correct Answer is ["B","C","D","E"]

Explanation

Pain level of 10 out of 10: Severe pain can stimulate the sympathetic nervous system and result in an increased heart rate.

Temperature 101.9°F: Fever can lead to an elevated heart rate as the body's response to infection or inﬂammation.

Hemoglobin: 7 g/dL: Low hemoglobin levels, known as anemia, can cause the heart to pump faster in an attempt to compensate for the decreased oxygen-carrying capacity of the blood.

Cocaine abuse: Cocaine is a stimulant drug that can signiﬁcantly increase heart rate and cause tachycardia.

The following clinical ﬁnding would not typically be associated with tachycardia:

Blood glucose 90 mg/dL: While low or high blood glucose levels can cause symptoms, they are not directly associated with tachycardia unless they lead to signiﬁcant physiological stress or hormonal imbalances.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure?

Correct Answer is A

Explanation

The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

The nurse is providing discharge education to a client who recently have insertion of a pacemaker/ICD. Which statement by the client should require further follow up by the nurse?

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

A nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the patient for?

The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

The nurse is teaching a client with atrial ﬂutter who is scheduled for a catheter ablation? What should the nurse include in the teaching plan?

The nurse is caring for a client with sinus bradycardia at a rate of 32 beats/min, blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which is the appropriate action?