The nurse is caring for client who is four days post-operative open repair of an abdominal aortic aneurysm the abdomen is distended. The client is complaining abdominal pain and the abdomen is distended. What action should the nurse take at this time?

Encourage the client to ambulate and perform deep breathing exercise

Notify the healthcare provider and prepare the client for further testing

Document the client's symptoms and continue to monitor.

Administer pain medication and explain this is normal.

Answer and Explanation

The Correct Answer is B

A) Encourage the client to ambulate and perform deep breathing exercises:
While ambulation and deep breathing exercises are important for post-operative recovery, they are not the priority intervention in this scenario. The client is presenting with abdominal distension and pain, which could indicate a potential complication such as bowel obstruction, ileus, or internal bleeding. These symptoms need to be thoroughly evaluated by the healthcare provider to rule out serious complications.

B) Notify the healthcare provider and prepare the client for further testing:
The combination of abdominal pain and distension in a client who is four days post-operative for an abdominal aortic aneurysm repair is concerning for potential complications such as bowel ischemia, internal bleeding, or post-operative ileus. It is essential to notify the healthcare provider immediately for further assessment and possible diagnostic tests, such as imaging or a physical exam to evaluate for signs of ischemia or obstruction

C) Document the client's symptoms and continue to monitor:
Although documenting and monitoring the client's symptoms is important in nursing care, it is not the most appropriate immediate response. Given the symptoms, including pain and abdominal distension, there is a potential for a serious complication, and simply continuing to monitor without notifying the healthcare provider could delay diagnosis and treatment.

D) Administer pain medication and explain this is normal:
While it is important to manage the client's pain, explaining that the symptoms are "normal" could lead to a delay in identifying a potentially serious issue. Abdominal distension and pain post-operatively in a patient who has undergone abdominal surgery should never be assumed to be a normal part of recovery without further investigation.

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Correct Answer is ["A","D","E"]

Explanation

A) If there is a QRS complex after each P wave:
This is an important consideration when identifying a cardiac rhythm. The P wave represents atrial depolarization, and the QRS complex represents ventricular depolarization. In a normal sinus rhythm, every P wave is followed by a QRS complex, which confirms that the impulse originating in the SA node is being conducted properly through the atrioventricular (AV) node and into the ventricles. The presence of a QRS after every P wave helps confirm normal conduction and rhythm.

B) The rate using only a 3-second strip:
While the heart rate is an essential part of the rhythm assessment, using only a 3-second strip is not the most accurate method for determining the rate. Typically, a 6-second strip is used to estimate the rate, multiplying the number of R-R intervals by 10 to obtain the heart rate. A 3-second strip can be used for quick estimates but may lead to inaccurate calculations of the heart rate.

C) The duration of the U waves:
The U wave is often a normal variant seen in the ECG and is not always present. If it is visible, its duration is typically not a primary focus in rhythm interpretation unless there are concerns about electrolyte imbalances, such as hypokalemia. The U wave is not a core factor to consider when identifying the overall rhythm.

D) If the P waves are present:
The presence of P waves is important for identifying the rhythm, particularly when differentiating between sinus rhythms (normal) and non-sinus rhythms (such as atrial arrhythmias). In normal sinus rhythm, P waves should be present, reflecting atrial depolarization initiated by the SA node. The absence of P waves can indicate atrial fibrillation, atrial flutter, or other arrhythmias.

E) If the P-P and R-R distances are equal:
This is crucial in identifying a regular rhythm. The P-P interval refers to the distance between successive P waves (atrial depolarization), and the R-R interval refers to the distance between successive R waves (ventricular depolarization). In normal sinus rhythm or regular rhythms, both the P-P and R-R intervals should be equal, indicating that the atrial and ventricular rhythms are consistent. If they are unequal, it suggests an irregular rhythm (e.g., atrial fibrillation).

A. Prolonged prothrombin time (PT) B. Elevated fibrinogen level C. Decreased platelet court D. Decreased D-dimer level

Correct Answer is D

Explanation

A) Prolonged prothrombin time (PT):
A prolonged PT is a sign of impaired coagulation, which is common in DIC as the clotting factors are consumed. In DIC, both clotting and bleeding occur, leading to prolonged PT. Therefore, a prolonged PT does not reflect a positive outcome. A positive outcome would show normalization or improvement of the clotting profile.

B) Elevated fibrinogen level:
Fibrinogen is often decreased in DIC because it is consumed in the process of forming clots. An elevated fibrinogen level would not indicate a positive outcome in DIC. Instead, fibrinogen levels typically fall in DIC due to widespread clotting activity. A positive outcome would involve a normalization or increase in fibrinogen levels as the condition improves.

C) Decreased platelet count:
Platelet count typically decreases in DIC because platelets are used up in the formation of clots, leading to thrombocytopenia. A decreased platelet count reflects ongoing consumption of platelets and would not be a positive indicator of improvement. In a positive outcome, the platelet count would increase toward normal levels.

D) Decreased D-dimer level:
D-dimer is a product of fibrin degradation and is elevated in conditions like DIC, where abnormal clotting and fibrinolysis are occurring. A decreased D-dimer level indicates that the coagulation process is resolving, and fibrin degradation is returning to normal, reflecting a positive outcome. Monitoring the D-dimer level is a key indicator of improvement in DIC.

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The nurse is caring for client who is four days post-operative open repair of an abdominal aortic aneurysm the abdomen is distended. The client is complaining abdominal pain and the abdomen is distended. What action should the nurse take at this time?

Nursing Test Bank

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is D

Explanation

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