The nurse is admitting the client with a thoracic aortic ane...

The nurse is admitting the client with a thoracic aortic aneurysm. Which intervention should the nurse plan to include?

A. Administering antihypertensive medications
B. Palpating the abdomen to determine the aneurysm’s size
C. Inserting a nasogastric tube set to moderate suction
D. Teaching about a diet high in potassium and low in sodium

Correct Answer: A

Rationale: The nurse should include administering antihypertensive medications to the client with a thoracic aortic aneurysm; controlling HR and BP is important to decrease the risk of aneurysm rupture. Palpation is contraindicated, and NG tubes or specific diets are not indicated.

You may also like to solve these questions

The nurse is discussing healthy lifestyle practices with the client who has chronic venous insufficiency. Which practices should be emphasized with this client? Select all that apply.

A. Avoid eating an excess of dark green vegetables.
B. Take rests and elevate the legs while sitting.
C. Wear graduated compression stockings, removing them at night.
D. Increase standing time and shift weight when upright.
E. Sleep with legs elevated above the level of the heart.

Correct Answer: B;C;E

Rationale: The nurse should emphasize: B) Elevating legs when sitting to promote venous return; C) Wearing compression stockings to reduce edema; E) Sleeping with legs elevated to enhance venous return. Avoiding dark green vegetables is relevant only with anticoagulants, and prolonged standing should be avoided.

The nurse is admitting the client experiencing dyspnea from HF and COPD with high CO2 levels. Which interventions should the nurse plan? Select all that apply.

A. Apply oxygen 6 liters per nasal cannula.
B. Elevate the head of the bed 30 to 40 degrees.
C. Weigh daily in the am. after the client voids.
D. Teach client pursed-lip breathing techniques.
E. Turn and reposition the client every 1 to 2 hours.

Correct Answer: B;C;D

Rationale: The nurse should plan: B) Elevating the head of the bed to promote lung expansion; C) Daily weights to assess fluid retention; D) Pursed-lip breathing to conserve energy and slow breathing. High oxygen flow (A) may depress hypoxic drive in COPD, and repositioning (E) is less specific to dyspnea management.

The nurse is giving discharge teaching to the client following aortic valve replacement surgery with a synthetic valve. The nurse evaluates that the client understands the teaching when the client states plans to take which action? Select all that apply.

A. Use a soft toothbrush for dental hygiene.
B. Floss teeth daily to prevent plaque.
C. Wear loose-fitting T-shirts or tops.
D. Use an electric razor for shaving.
E. Consume foods high in vitamin K.

Correct Answer: A;C;D

Rationale: The client understands when stating: A) Using a soft toothbrush to reduce bleeding risk on anticoagulants; C) Wearing loose-fitting clothing to avoid incision friction; D) Using an electric razor to prevent cuts. Flossing (B) increases bleeding and endocarditis risk, and high vitamin K (E) antagonizes anticoagulants.

The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?

A. Recheck the pulse in 5 minutes.
B. Reposition the affected leg.
C. Notify the surgeon of the finding.
D. Document that the pulse is absent.

Correct Answer: C

Rationale: The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse could signify graft occlusion or embolization. Rechecking, repositioning, or documenting delays critical intervention.

The nurse is assessing the client. At which area should the nurse place the stethoscope to best auscultate the client’s murmur associated with mitral regurgitation?

A. Line A
B. Line B
C. Line C
D. Line D

Correct Answer: D

Rationale: Mitral regurgitation is heard at the location of the mitral valve (line D) and should be auscultated with the bell of the stethoscope at the fifth intercostal space, left midclavicular line. The bell is used to auscultate low-pitched sounds. Lines A, B, and C correspond to aortic, pulmonic, and tricuspid valves, respectively.