The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:
monitoring for dysrhythmias
monitoring for bleeding.
adherence to their antihypertensive drugs
preventing thrombus formation.
The Correct Answer is C
A. Monitoring for dysrhythmias
While cardiovascular health is important, dysrhythmias are not a primary concern in a small abdominal aortic aneurysm.
B. Monitoring for bleeding
While aneurysms can rupture, a small aneurysm is managed medically with blood pressure control, making bleeding less of an immediate concern.
C. Adherence to their antihypertensive drugs
Hypertension increases pressure on the aneurysm, increasing the risk of expansion and rupture. Strict adherence to antihypertensive medications is essential for preventing complications.
D. Preventing thrombus formation
While thrombus formation can occur in large aneurysms, it is not the primary focus in a small, medically managed aneurysm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.
B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.
C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.
D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.
Correct Answer is B
Explanation
A. 20-gauge catheter in the right wrist infusing IV antibiotics
Infusing antibiotics can cause incompatibilities.
B. 20-gauge catheter in the right forearm infusing 0.9% Normal Saline
A 20-gauge or larger catheter in a patent IV site with compatible fluid (NS) is required for PRBC transfusion.
C. 22-gauge catheter in the left forearm infusing 0.45% Normal Saline
A 22-gauge catheter is too small for safe transfusion.
D. 18-gauge infusing 20 mg Potassium Chloride IV
Potassium chloride infusion should not be interrupted, making this site unsuitable.
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