Nokea
The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first?
- A. Assess the client’s bowel sounds.
- B. Administer an IV prophylactic antibiotic.
- C. Encourage the client to splint the incision.
- D. Ambulate the client in the room with assistance.
Correct Answer: A
Rationale: Assessing bowel sounds (A) is first to detect ileus, common post-AAA repair. Antibiotics (B), splinting (C), and ambulation (D) follow based on assessment.
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Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm (AAA)?
- A. Shortness of breath.
- B. Abdominal bruit.
- C. Ripping abdominal pain.
- D. Decreased urinary output.
Correct Answer: B
Rationale: An abdominal bruit (B) is a key sign of AAA due to turbulent flow. Shortness of breath (A) is nonspecific, ripping pain (C) suggests dissection, and low urine output (D) is a complication, not diagnostic.
The nurse is teaching a client with cardiomyopathy about implantable cardioverter-defibrillators (ICDs). Which statement is accurate?
- A. It will prevent all arrhythmias.
- B. It delivers a shock if a dangerous rhythm occurs.
- C. It replaces the need for medications.
- D. It requires replacement every 2 years.
Correct Answer: B
Rationale: An ICD monitors heart rhythm and delivers a shock to restore normal rhythm in life-threatening arrhythmias.
The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).
The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first?
- A. Recommend that the client have his blood pressure checked in one (1) month.
- B. Instruct the client to see his health-care provider as soon as possible.
- C. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet.
- D. Explain that this BP is within the normal range for an elderly person.
Correct Answer: B
Rationale: BP 168/98 indicates stage 2 hypertension, requiring prompt HCP evaluation (B). Waiting a month (A) delays care, diet discussion (C) is secondary, and normal range (D) is incorrect (normal is <120/80).
Which assessment data would support that the client has a venous stasis ulcer?
- A. A superficial pink open area on the medial part of the ankle.
- B. A deep pale open area over the top side of the foot.
- C. A reddened blistered area on the heel of the foot.
- D. A necrotic gangrenous area on the dorsal side of the foot.
Correct Answer: A
Rationale: Venous stasis ulcers are superficial, pink, and medial (A) due to venous pooling. Deep/pale (B) or necrotic (D) ulcers suggest arterial insufficiency, and blisters (C) are unrelated.