A nurse is caring for a client who has an abdominal aortic aneurysm and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?

Administer supplemental oxygen.

Have the client sit down.

Check the client’s vital signs.

Notify the provider immediately.

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering oxygen is premature without assessing the cause of chest heaviness. While hypoxia may occur in aneurysm rupture, stopping exertion reduces cardiovascular demand first, prioritizing safety in a client with an abdominal aortic aneurysm at risk for rupture.
Choice B reason: Having the client sit down is the priority, as chest heaviness may signal aneurysm instability. Rest reduces aortic wall stress and oxygen demand, preventing rupture or dissection, stabilizing the client for further assessment and intervention in this high-risk condition.
Choice C reason: Checking vital signs is important but secondary to stopping exertion. Chest heaviness suggests potential aneurysm rupture, and continued ambulation risks catastrophe. Sitting the client minimizes cardiovascular stress, allowing subsequent vital sign checks to guide further actions effectively.
Choice D reason: Notifying the provider is critical but not first. Chest heaviness requires immediate cessation of activity to reduce aortic pressure. Sitting stabilizes the client, allowing data collection (e.g., vital signs) before provider notification, ensuring urgent intervention for potential aneurysm complications.

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Correct Answer is A

Explanation

Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.

A. Add salt to season foods. B. Rinse your mouth with an alcohol-based mouthwash. C. Eat foods served at hot temperatures. D. Use ice chips to numb your mouth.

Correct Answer is D

Explanation

Choice A reason: Adding salt to season foods can irritate oral sores in AIDS patients, often caused by candidiasis or herpes. Salt exacerbates pain and delays healing, making this instruction harmful and inappropriate for managing oral discomfort in this population.
Choice B reason: Rinsing with alcohol-based mouthwash worsens oral soreness, as alcohol irritates mucosal lesions common in AIDS. Non-alcohol, antiseptic, or saline rinses are preferred to promote comfort and healing, making this instruction incorrect and potentially painful.
Choice C reason: Eating hot foods can aggravate oral sores, increasing pain and delaying healing in AIDS patients with mucosal damage. Lukewarm or cool foods are better tolerated, making this instruction inappropriate and counterproductive for managing the client’s symptoms.
Choice D reason: Using ice chips numbs the mouth, reducing pain from oral sores during eating for AIDS patients. This non-invasive, soothing intervention is safe and effective, aligning with comfort-focused care for mucosal lesions, making it the correct instruction.

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A nurse is caring for a client who has an abdominal aortic aneurysm and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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