To reduce the risk of aneurysm rupture, the nurse should implement all of the following except.

Maintain bedrest with the legs elevated.

Administer antihypertensive and beta-blockers as prescribed.

Instruct client to prevent straining during defecation and avoid holding the breath while moving.

Maintain a calm environment and implement measures to reduce psychologic stress.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Elevating the legs is contraindicated for a client with an aneurysm because it can increase venous return and subsequently increase the pressure within the arterial system. For an abdominal or thoracic aneurysm, the goal is to keep systemic blood pressure low and stable to prevent wall stress. Bedrest is often encouraged, but the legs should remain flat or in a neutral position to avoid any unintended increases in central venous or arterial pressures.

Choice B rationale

Administering antihypertensive medications and beta blockers is a standard evidence based intervention for managing aneurysms. These drugs work by lowering the systemic blood pressure and reducing the heart rate, which decreases the force of blood hitting the weakened vessel wall. By minimizing the dP/dt, or the rate of pressure rise, these medications significantly reduce the risk of dissection or rupture. Maintaining a systolic blood pressure within a narrow, low range is the clinical priority.

Choice C rationale

Preventing straining during defecation is crucial because the Valsalva maneuver significantly increases intra abdominal and intra thoracic pressure. This sudden spike in pressure can place excessive stress on the aneurysmal sac, potentially leading to an immediate rupture. Nurses provide stool softeners and educate clients on proper breathing techniques to ensure that they do not hold their breath or exert themselves physically, thereby maintaining a stable and safe internal pressure environment.

Choice D rationale

Psychological stress triggers the sympathetic nervous system, leading to the release of cortisol and adrenaline. These hormones cause vasoconstriction and increase the heart rate and blood pressure, all of which increase the tension on the arterial wall. By maintaining a calm environment and using stress reduction techniques, the nurse helps keep the client's hemodynamics stable. This holistic approach is essential for preventing the physiological spikes that lead to the catastrophic failure of the aneurysm.

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

Explanation

Choice A rationale

Assessing peripheral pulses distal to the insertion site is a critical nursing intervention following cardiac catheterization. The procedure involves arterial puncture, which carries a risk of arterial occlusion, thrombosis, or embolism. Regular pulse checks help ensure that blood flow to the extremity remains adequate. Comparing the pulse strength to the baseline and the unaffected limb allows for early detection of vascular compromise, which requires immediate intervention to prevent permanent tissue damage or limb ischemia.

Choice B rationale

The insertion site for a cardiac catheterization, usually the femoral or radial artery, must be monitored closely for bleeding or hematoma formation. Because the procedure involves a large-bore puncture in a high-pressure vessel, the risk of hemorrhage is significant, especially if the patient is on anticoagulants. A hematoma can also lead to local tissue compression or nerve injury. Frequent visual inspection and palpation of the site are necessary to ensure the effectiveness of the pressure dressing.

Choice C rationale

Evaluating the temperature and color of the affected extremity provides essential data regarding the neurovascular status. A cold, pale, or cyanotic limb suggests impaired arterial circulation or a possible clot at the puncture site. Monitoring these parameters alongside pulse checks provides a comprehensive assessment of perfusion. If the extremity becomes cool or mottled, it indicates a medical emergency such as an acute arterial occlusion, which is a known complication of invasive percutaneous cardiovascular procedures.

Choice D rationale

Early ambulation is usually contraindicated immediately following cardiac catheterization if a femoral approach was used. Patients are typically required to remain on bed rest with the affected extremity kept straight for several hours to prevent arterial bleeding and allow the puncture site to seal properly. Encouraging ambulation too soon increases the risk of hematoma formation or retroperitoneal hemorrhage. Therefore, the nurse must enforce strict activity restrictions according to the facility protocol rather than encouraging early movement.

Choice E rationale

Restricting fluid intake is generally contraindicated after cardiac catheterization unless the patient has a specific condition like severe heart failure. Patients receive radiopaque contrast dye during the procedure, which is nephrotoxic. Increasing fluid intake, either orally or intravenously, is encouraged to help flush the dye through the kidneys and prevent contrast-induced nephropathy. Adequate hydration ensures that the concentration of the dye in the renal tubules is minimized, thereby protecting the patient's renal function post-procedure.

A. Administer nitroglycerin immediately to reduce chest pain and lower blood pressure regardless of hemodynamic status. B. Administer supplemental oxygen to maintain saturation above 94 C. Place the patient in supine position to optimize cardiac output and prepare for administration of morphine for pain control. D. Start thrombolytic therapy immediately as first-line treatment before obtaining vascular access or ECG monitoring.

Correct Answer is B

Explanation

Choice A rationale

Administering nitroglycerin is a standard treatment for chest pain because it induces vasodilation of the coronary arteries. However, prioritizing it over oxygen in a patient with an oxygen saturation of 89 percent is incorrect. Nitroglycerin can significantly lower blood pressure, and it should only be administered after assessing hemodynamic stability. In this clinical scenario, addressing the documented hypoxemia takes precedence to ensure myocardial tissue receives adequate oxygenation to prevent further ischemic damage.

Choice B rationale

Supplemental oxygen is the priority because the patient is hypoxemic, with a saturation below the normal range of 95 to 100 percent. Oxygen therapy increases the partial pressure of oxygen in the blood, enhancing delivery to the myocardium. Correcting hypoxemia reduces the workload on the heart and limits the size of the infarction. Current guidelines emphasize maintaining oxygen saturation at or above 94 percent to optimize cellular respiration and prevent systemic metabolic acidosis.

Choice C rationale

The supine position is not ideal for a patient experiencing chest pain and respiratory distress because it increases venous return and cardiac preload, potentially worsening pulmonary congestion. Positioning the patient in semi-Fowler or high-Fowler position is usually preferred to facilitate lung expansion. While morphine is used for pain that is unresponsive to nitrates, it is not the first priority. Oxygenation must be addressed immediately to mitigate the underlying cause of the myocardial hypoxia.

Choice D rationale

Thrombolytic therapy is a critical intervention for ST-segment elevation myocardial infarction when percutaneous intervention is unavailable, but it is never initiated before establishing vascular access and confirming the diagnosis via a 12-lead ECG. Furthermore, safety screening for contraindications like recent surgery or bleeding disorders is mandatory. Starting this treatment without basic stabilization, such as oxygen administration for a desaturating patient, violates the primary assessment sequence of airway, breathing, and circulation.

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To reduce the risk of aneurysm rupture, the nurse should implement all of the following except.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? Select all that apply.

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

Explanation

A patient is admitted to the emergency department with chest pain and ECG findings showing ST-segment elevation. The nurse notes oxygen saturation at 89 Which intervention should the nurse prioritize to initiate first?

Correct Answer is B

Explanation

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