The nurse is caring for a client in the intensive care unit (ICU) who is mechanically ventilated and sedated following an emergency abdominal aortic aneurysm (AAA) repair. Which assessment warrants immediate intervention by the nurse?

No spontaneous respirations over set rate.

Abdominal girth increase of 2 inches (5.1 cm).

Urine output less than fluid intake.

Core body temperature of 101° F (38.3° C)

Answer and Explanation

The Correct Answer is A

Rationale:
A. No spontaneous respirations over set rate: Absence of spontaneous respirations in a mechanically ventilated client indicates inadequate ventilation or possible ventilator malfunction. Immediate intervention is required to prevent hypoxia and respiratory arrest.

B. Abdominal girth increase of 2 inches (5.1 cm): While this may indicate internal bleeding or fluid accumulation after AAA repair, it is not immediately life-threatening compared to absent respirations. It requires urgent monitoring and notification but does not take precedence over airway and ventilation.

C. Urine output less than fluid intake: Reduced urine output may suggest hypoperfusion or early renal compromise. This requires ongoing monitoring and intervention but is not as acutely critical as inadequate ventilation.

D. Core body temperature of 101° F (38.3° C): Mild fever may occur postoperatively and should be monitored for infection. While important, it does not require the immediate action that absent respirations demand.

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Correct Answer is D

Explanation

Rationale:
A. Administer an antipyretic agent: The client has a mild fever (100°F), but fever is not the priority concern in the context of hypotension, tachycardia, and low urine output. Treating the fever will not address potential hypovolemia or shock.

B. Titrate IV vasopressor for systolic less than 80: Vasopressors are indicated for persistent hypotension unresponsive to fluid resuscitation. The client’s systolic BP is 88 mm Hg, so initial management should focus on restoring intravascular volume before starting vasopressors.

C. Place a cooling blanket on the client: Cooling measures are used for high fevers. The client’s temperature is only mildly elevated, and addressing fluid status takes priority over lowering temperature at this stage.

D. Give a 500 mL IV fluid bolus challenge: Hypotension, tachycardia, and oliguria indicate possible hypovolemic or distributive shock postoperatively. Administering a fluid bolus helps restore intravascular volume, improve perfusion, and increase urine output, making it the most urgent intervention.

A. Determine when symptoms began and if improved or worsened since onset. B. Administer aspirin to prevent further clot formation and platelet clumping. C. Verify prescribed laboratory tests include prothrombin time and platelet count. D. Keep the bed in the lowest position and initiate seizure and fall precautions.

Correct Answer is A

Explanation

Rationale:
A. Determine when symptoms began and if improved or worsened since onset: In suspected stroke, the timing of symptom onset is critical for determining eligibility for interventions such as thrombolytic therapy. Assessing whether symptoms are improving or worsening guides immediate treatment decisions and is the highest priority.

B. Administer aspirin to prevent further clot formation and platelet clumping: Administering aspirin may be contraindicated if the stroke is hemorrhagic. The type of stroke must first be determined via imaging before giving antiplatelet therapy.

C. Verify prescribed laboratory tests include prothrombin time and platelet count: Lab tests are important for baseline data and to guide future treatment, but they do not take priority over determining the timing and progression of neurological symptoms.

D. Keep the bed in the lowest position and initiate seizure and fall precautions: Safety measures are important to prevent injury but are secondary to establishing the timeline and nature of the neurological event, which drives urgent treatment.

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The nurse is caring for a client in the intensive care unit (ICU) who is mechanically ventilated and sedated following an emergency abdominal aortic aneurysm (AAA) repair. Which assessment warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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The nurse is caring for a client in the intensive care unit (ICU) who is mechanically ventilated and sedated following an emergency abdominal aortic aneurysm (AAA) repair. Which assessment warrants immediate intervention by the nurse?

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