Which of the following interventions should the nurse expect when planning care for this client?

Choice A rationale

Jugular distention is a classic sign of right-sided heart failure. In right-sided heart failure, the right ventricle is unable to effectively pump blood to the lungs, leading to increased pressure in the right atrium and systemic venous circulation. This increased venous pressure causes the jugular veins in the neck to become distended, especially when the client is in a semi-recumbent position.

Choice B rationale

Frothy sputum is a common finding in left-sided heart failure. When the left ventricle fails to pump blood effectively, pressure increases in the left atrium and pulmonary veins. This increased pressure forces fluid into the alveoli, leading to pulmonary edema. The fluid mixes with air in the alveoli, producing a characteristic frothy, often pink-tinged sputum.

Choice C rationale

Dependent edema, such as swelling in the legs and ankles, is more characteristic of right-sided heart failure. It occurs due to the increased systemic venous pressure, which causes fluid to accumulate in the dependent areas of the body due to gravity. While left-sided heart failure can eventually lead to systemic congestion and edema, it is not the primary early finding.

Choice D rationale

Nocturnal polyuria, or increased urination at night, is a common symptom of left-sided heart failure. During the day, fluid accumulates in the dependent extremities due to decreased cardiac output and increased venous pressure. When the client lies down at night, this fluid is redistributed to the central circulation, increasing renal blood flow and leading to increased urine production.

Choice A rationale

Monitoring for abdominal pain is a crucial intervention for a client with an abdominal aortic aneurysm. Sudden or severe abdominal pain can indicate expansion or rupture of the aneurysm, a life-threatening emergency requiring immediate intervention.

Choice B rationale

Providing education regarding the manifestations of an increasing aneurysm, such as persistent or severe abdominal, back, or flank pain, pulsatile sensation in the abdomen, or coolness and cyanosis of the extremities, empowers the client to recognize potential complications and seek timely medical attention.

Choice C rationale

Administering an antihypertensive agent is a key intervention to manage hypertension, a significant risk factor for AAA growth and rupture. Maintaining optimal blood pressure reduces stress on the aortic wall, slowing the rate of aneurysm expansion. Normal blood pressure is typically less than 120/80 mmHg.

Choice D rationale

Monitoring for back pain is essential as it can be a symptom of an expanding or leaking abdominal aortic aneurysm. The pain often radiates to the back, flank, or groin and can be severe and persistent.

Choice E rationale

Analyzing complete blood count (CBC) results can provide information about the client's overall health status, including hemoglobin and hematocrit levels, which may be affected by a leaking or ruptured aneurysm. However, it is not a primary intervention in the immediate management of a stable AAA. Normal hemoglobin for males is 13.5-17.5 g/dL and for females is 12.0-15.5 g/dL. Normal hematocrit for males is 41-53% and for females is 36-46%.

Choice F rationale

Providing education regarding smoking cessation is a vital long-term intervention. Smoking is a major risk factor for AAA development and progression, and quitting can significantly reduce the risk of rupture and improve overall cardiovascular health.

Choice G rationale

Preparing the client for emergency surgery is a critical intervention if the abdominal aortic aneurysm ruptures or shows signs of rapid expansion and impending rupture. Prompt surgical repair is necessary to improve the client's chances of survival.