Nokea
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
- A. Assess peripheral circulation.
- B. Monitor for abdominal distention.
- C. Educate the client that abdominal pain is to be expected.
- D. Assess the client for observable ecchymoses on the lower back.
- E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
Correct Answer: A,B,D
Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.
You may also like to solve these questions
A client undergoes transurethral resection of the prostate (TURP). Which solution should the nurse have available postoperatively for continuous bladder irrigation (CBI)?
- A. Sterile water
- B. Sterile normal saline
- C. Sterile Dakin's solution
- D. Sterile water with 5% dextrose
Correct Answer: B
Rationale: Continuous bladder irrigation is done after TURP using sterile normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly kidney failure. Dakin's solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not introduced into the bladder.
A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. Which should the nurse assess the client for before the procedure to best assure the client's safety?
- A. Allergies
- B. Familial renal disease
- C. Frequent antibiotic use
- D. Long-term diuretic therapy
Correct Answer: A
Rationale: The client undergoing any type of diagnostic testing involving possible dye administration should be questioned about allergies, specifically an allergy to shellfish or iodine. This is essential to identify the risk for potential allergic reaction to contrast dye, which may be used.
The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 mEq/L (0.375 mmol/L). Which action should the nurse take?
- A. Monitor the client for irregular heart rhythms.
- B. Encourage the intake of antacids with phosphate.
- C. Teach the client to avoid foods high in magnesium.
- D. Provide a diet of ground beef, eggs, and chicken breast.
Correct Answer: A
Rationale: The normal magnesium level ranges from 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L); therefore, this client is experiencing hypomagnesemia. The client should be monitored for dysrhythmias because magnesium plays an important role in myocardial nerve cell impulse conduction; thus, hypomagnesemia increases the client's risk of ventricular dysrhythmias. The nurse avoids administering phosphate in the presence of hypomagnesemia because it aggravates the condition. The nurse instructs the client to consume foods high in magnesium; ground beef, eggs, and chicken breast are low in magnesium.
A child sustains a greenstick fracture of the humerus from a fall out of a tree house. The nurse describes this type of fracture to the parents and should provide them with which picture? Refer to figures 1 to 4.
- A. fracture_1.PNG
- B. fracture_2.PNG
- C. fracture_3.PNG
- D. fracture_4.PNG
Correct Answer: A
Rationale: A greenstick fracture is an incomplete fracture where the bone bends and breaks on one side without breaking completely through, common in children due to their flexible bones. The nurse should select the picture that depicts this type of fracture, typically showing a bend with a partial break on one side of the bone. This distinguishes it from complete fractures or other types like comminuted or spiral fractures.
The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?
- A. Leave the child uncovered for 15 minutes.
- B. Assist the child to put on a cotton sleep shirt.
- C. Take the child's axillary temperature in 2 hours.
- D. Place the child in bed and cover the child with a blanket.
Correct Answer: B
Rationale: Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option 1 is incorrect because the child should not be left uncovered. Option 3 is incorrect because the child's temperature should be reassessed a half hour after the bath. Option 4 is incorrect because a blanket is heavy and may increase the child's body temperature.