Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair?
Absent bilateral pedal pulses.
Complaints of pain at the site of the incision.
Distended, tender abdomen.
An elevated temperature of 100 F
The Correct Answer is A
Absent bilateral pedal pulses indicate a potential vascular complication, such as impaired circulation or blood flow to the lower extremities. It may suggest compromised perfusion and could be a sign of arterial occlusion or thrombosis, which requires immediate intervention. The nurse should notify the healthcare provider promptly to assess the client's condition and initiate appropriate interventions to restore circulation to the lower extremities.
While complaints of pain at the site of the incision are significant, post-operative pain is expected after abdominal surgery. The nurse should assess the pain and provide appropriate pain management interventions, but it may not require immediate intervention unless the pain is severe or accompanied by other concerning symptoms.
A distended, tender abdomen could indicate various post-operative complications, such as bowel obstruction or peritonitis. Although it should be evaluated and reported to the healthcare provider, it may not require immediate intervention unless the client's condition deteriorates or other signs of a surgical emergency are present.
An elevated temperature of 100°F (37.8°C) alone, without other signs of infection or systemic complications, may not necessarily require immediate intervention. It could be a normal response to surgery or a mild post-operative infection. The nurse should monitor the client's temperature and assess for other signs of infection, and if necessary, report it to the healthcare provider for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The procedure uses electrical energy to destroy areas of the conduction system: Catheter ablation is a minimally invasive procedure performed to treat abnormal heart rhythms, such as atrial flutter. During the procedure, a catheter is inserted into the heartand used to deliver electrical energy to specific areas of the heart tissue. This energy is used to destroy or ablate the abnormal conduction pathways that are causing the atrial flutter.
Let's go through the other options and explain why they are not accurate:
The procedure stimulates the growth of new pathways between the atria: Catheter ablation does not stimulate the growth of new pathways. Instead, it aims to eliminate or modify existing abnormal pathways in the heart to restore normal electrical conduction.
The procedure uses cold therapy to stop the formation of the flutter waves: Catheter ablation does not use cold therapy. It primarily utilizes radiofrequency energy or other sources of heat to ablate the targeted areas of the heart tissue.
The procedure prevents or minimizes the patient's risk for sudden cardiac death: While catheter ablation can be an effective treatment for certain arrhythmias, including atrial flutter, it is not primarily performed to prevent or minimize the risk of sudden cardiac death. Its main purpose is to restore normal heart rhythm and alleviate symptoms associated with the arrhythmia.
Correct Answer is A
Explanation
Absent bilateral pedal pulses indicate a potential vascular complication, such as impaired circulation or blood flow to the lower extremities. It may suggest compromised perfusion and could be a sign of arterial occlusion or thrombosis, which requires immediate intervention. The nurse should notify the healthcare provider promptly to assess the client's condition and initiate appropriate interventions to restore circulation to the lower extremities.
While complaints of pain at the site of the incision are significant, post-operative pain is expected after abdominal surgery. The nurse should assess the pain and provide appropriate pain management interventions, but it may not require immediate intervention unless the pain is severe or accompanied by other concerning symptoms.
A distended, tender abdomen could indicate various post-operative complications, such as bowel obstruction or peritonitis. Although it should be evaluated and reported to the healthcare provider, it may not require immediate intervention unless the client's condition deteriorates or other signs of a surgical emergency are present.
An elevated temperature of 100°F (37.8°C) alone, without other signs of infection or systemic complications, may not necessarily require immediate intervention. It could be a normal response to surgery or a mild post-operative infection. The nurse should monitor the client's temperature and assess for other signs of infection, and if necessary, report it to the healthcare provider for further evaluation.
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