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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Performing postural drainage immediately after meals risks aspiration and discomfort due to gastric contents shifting during positioning. It should be done 1-2 hours after meals to ensure safety and efficacy in clearing mucus from the lungs, making this timing inappropriate for cystic fibrosis management.
Choice B reason: Performing postural drainage twice daily is recommended for cystic fibrosis to mobilize thick mucus from the lungs, improving airway clearance and reducing infection risk. This frequency balances effectiveness with patient tolerance, aligning with evidence-based guidelines for managing chronic respiratory conditions, making it the correct action.
Choice C reason: Using a percussion vest is an alternative to manual postural drainage but is not specified as the only method. Manual techniques are effective and standard unless a vest is prescribed. This choice assumes equipment availability, which may not apply, making it less universally appropriate than scheduled manual drainage.
Choice D reason: Positioning the child flat during postural drainage is incorrect, as specific angled positions (e.g., head-down) are needed to target lung segments and promote mucus drainage by gravity. Flat positioning reduces effectiveness and may not clear airways adequately, making this an inappropriate technique for cystic fibrosis.

A. Dehydration is associated with gastroesophageal reflux. B. Dehydration is caused by decreased hemoglobin and hematocrit. C. Dehydration can increase the risk for preterm labor. D. Dehydration is treated with calcium supplements.

Correct Answer is C

Explanation

Choice A reason: Dehydration is not directly associated with gastroesophageal reflux, which involves gastric acid backflow. Dehydration affects fluid balance, not reflux mechanisms, so this statement is inaccurate and irrelevant to preterm contractions, making it incorrect.
Choice B reason: Dehydration is not caused by decreased hemoglobin and hematocrit; rather, it may elevate these due to hemoconcentration. This statement reverses the relationship, making it factually incorrect and unrelated to preterm labor risks.
Choice C reason: Dehydration can increase preterm labor risk by reducing uterine blood flow and triggering contractions via oxytocin release. This evidence-based link supports hydration as a preventive measure, making it the correct statement for teaching in this scenario.
Choice D reason: Dehydration is treated with fluid replacement, not calcium supplements, which address bone health or specific deficiencies. This treatment is irrelevant to dehydration or preterm labor, making it an incorrect and inappropriate recommendation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is talking with the parents of a 2-month-old infant who have chosen to not immunize the infant. Which of the following responses should the nurse make?

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?