Nokea
A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown below. What is most likely contributing to the client's abdominal distention?
- A. Bowel obstruction
- B. Paralytic ileus
- C. Peritonitis
- D. Wound dehiscence
Correct Answer: B
Rationale: Abdominal distention 2 days post-AAA repair is most likely due to paralytic ileus, a common postoperative complication from bowel manipulation and anesthesia, causing slowed gut motility. Bowel obstruction, peritonitis, or wound dehiscence would present with additional symptoms (e.g., fever, vomiting, or wound disruption).
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A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will:
- A. Avoid heating pads
- B. Not cross her legs
- C. Wear leather shoes
- D. Use iodine on an injured site
Correct Answer: D
Rationale: Using iodine on an injured site is incorrect, as it can be cytotoxic and impair wound healing in PVD, where tissue perfusion is already compromised. Avoiding heating pads (risk of burns), not crossing legs (improves circulation), and wearing leather shoes (protects feet) are appropriate self-care measures.
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as an increased risk for developing primary open-angle glaucoma? Select all that apply.
- A. Blue eyes
- B. Older age
- C. African ethnicity
- D. Diabetes mellitus
- E. Use of contact lenses
Correct Answer: B,C,D
Rationale: Older age, African ethnicity, and diabetes mellitus are known risk factors for primary open-angle glaucoma due to increased intraocular pressure susceptibility. Blue eyes and contact lens use are not established risk factors.
A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities should the nurse instruct the client to avoid?
- A. Crossing the legs while sitting down.
- B. Sitting on a raised commode seat.
- C. Using an abductor splint while lying on the side.
- D. Rising straight from a chair to a standing position.
Correct Answer: A
Rationale: Crossing the legs risks hip dislocation post-surgery.
A client who has a history of mitral valve prolapse tells the nurse that she is scheduled to get her teeth cleaned. Which of the following replies by the nurse is most appropriate?
- A. The physician will need to reevaluate the status of your heart condition before your dental appointment.'
- B. The nurse to remind your dentist that you have a heart condition.'
- C. It is important for you to care for your teeth because your heart condition makes you more susceptible to developing oral infections.'
- D. We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned.'
Correct Answer: D
Rationale: Clients with mitral valve prolapse may require prophylactic antibiotics before dental procedures to prevent infective endocarditis, depending on current guidelines. This is the most appropriate response as it directly addresses the need for preventive measures. The other options either lack specificity or do not address the immediate clinical concern.
If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the client to do with following?
- A. Apply an ice pack to the pubic area.
- B. Massage the abdomen gently.
- C. Ambulate as much as possible.
- D. Sit in a tub of warm water.
Correct Answer: D
Rationale: Sitting in warm water can soothe bladder irritation and relax pelvic muscles, alleviating lower abdominal pain post-cystoscopy.