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 B

Explanation

A) Treatment plan will need to be changed to achieve the desired effect:
The decrease in the carcinoembryonic antigen (CEA) levels from 50 ng/mL to 10 ng/mL suggests that the cancer is responding to the current treatment, not that the treatment plan needs to be changed. A drop in CEA levels typically indicates a positive response to treatment, such as chemotherapy, in reducing the number or size of cancer cells.

B) Cancer treatment is having the desired effect on killing cancer cells:
Carcinoembryonic antigen (CEA) is a tumor marker that is often elevated in individuals with certain cancers, particularly colorectal cancer. A decrease in CEA levels, as noted in this case (from 50 ng/mL to 10 ng/mL), usually signifies that the treatment is successfully targeting the cancer and reducing the tumor burden. This drop suggests that the chemotherapy is effectively killing cancer cells and reducing the size or activity of the tumor.

C) Client is at greater risk for tumor lysis syndrome:
Tumor lysis syndrome typically occurs when large numbers of cancer cells die rapidly, releasing their intracellular contents into the bloodstream, which can lead to metabolic disturbances like hyperkalemia, hyperphosphatemia, and renal failure. It is more common in aggressive hematologic cancers, such as leukemia or lymphoma, and typically presents with a rapid rise in tumor marker levels, not a decrease.

D) Cancer has increased size and metastatic sites:
An increase in tumor size or the development of metastatic sites would typically result in an increase in CEA levels, not a decrease. Since CEA levels have dropped, it is more likely that the cancer is shrinking or responding to the current treatment. This finding is more indicative of a positive response rather than disease progression.

A. Tachycardia B. Crackles C. Ascites D. Dyspnea E. Peripheral edema

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

Explanation

A) Tachycardia: Tachycardia is commonly seen in left-sided heart failure as the heart attempts to compensate for the reduced cardiac output. To maintain adequate perfusion, the body increases the heart rate. The sympathetic nervous system is activated, causing an increase in heart rate to try to pump blood more efficiently despite the reduced pumping ability of the left ventricle.

B) Crackles: Crackles (also known as rales) are typically heard upon auscultation of the lungs in patients with left-sided heart failure. When the left ventricle fails to effectively pump blood, it causes blood to back up into the lungs, resulting in pulmonary congestion. This leads to fluid accumulation in the alveoli, causing crackling sounds during inhalation.

C) Ascites: Ascites is more commonly seen in right-sided heart failure or in cases of congestive heart failure where both sides of the heart are affected. Ascites is the accumulation of fluid in the abdomen, which is a consequence of right-sided heart failure causing blood to back up into the abdomen. In left-sided heart failure, ascites is generally not a primary symptom unless the failure becomes severe and involves both sides of the heart.

D) Dyspnea: Dyspnea, or shortness of breath, is a hallmark symptom of left-sided heart failure. The left ventricle's inability to pump blood efficiently leads to pulmonary congestion, which causes fluid to accumulate in the lungs. This fluid buildup reduces the lung's ability to exchange oxygen, resulting in difficulty breathing, especially on exertion or when lying down (orthopnea).

E) Peripheral edema: Peripheral edema is more characteristic of right-sided heart failure due to the backup of blood in the systemic circulation. While it can occur in cases of biventricular heart failure (both right and left sides of the heart are affected), it is not the primary finding in left-sided heart failure. Left-sided heart failure typically presents with pulmonary symptoms rather than systemic symptoms like peripheral edema.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

Correct Answer is B

Explanation

The nurse is performing an assessment of a client admitted with left sided heart failure. Which dinical manifestation(s) would the nurse expect to identify? SELECT ALL THAT APPLY)

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

Explanation

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