A nurse is caring for a client with a history of an abdominal aortic aneurysm (AAA). Which of the following assessments should be the nurse's priority for a client with an abdominal aortic aneurysm?

Deep palpation of the abdomen

Review of chest x-ray

Assessing the client’s pain

Assessment of blood pressure

Answer and Explanation

The Correct Answer is D

A. Deep palpation of the abdomen is contraindicated in clients with an AAA, as it may cause rupture.
B. A chest X-ray may detect an aneurysm, but it is not the priority assessment.
C. Pain assessment is important, as sudden severe pain could indicate rupture, but it is not the first priority.
D. Blood pressure assessment is the priority, as hypertension can increase the risk of aneurysm rupture. Strict BP control is critical to preventing complications.

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Correct Answer is B

Explanation

A. While cardiac rehab does help recovery, this statement does not emphasize the safety and long-term benefits of supervised rehabilitation.
B. Providing education about the role of cardiac rehab is essential. Cardiac rehab monitors the client's progress and helps safely return them to an active lifestyle.
C. While this statement acknowledges the client's feelings, it does not provide enough information about the benefits of cardiac rehab.
D. This response is too authoritative and does not address the client’s concerns or autonomy.

A. The client has an INR of 2. B. The client has an aPTT of 80 seconds. C. The client experiences sudden weakness of one arm and leg. D. The client's ECG tracing shows irregular heart rate without P waves.

Correct Answer is C

Explanation

A. An INR of 2 is within the therapeutic range for anticoagulation but is more relevant for warfarin therapy rather than heparin.
B. An aPTT of 80 seconds is slightly elevated but not immediately life-threatening. The therapeutic range for heparin is typically 1.5 to 2.5 times the normal value (approximately 60-80 seconds).
C. Sudden weakness of one arm and leg suggests a possible embolic stroke, which is a serious complication of atrial fibrillation. This requires immediate assessment and intervention.
D. An irregular heart rate without P waves is characteristic of atrial fibrillation but is not the most urgent concern compared to potential stroke symptoms.

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A nurse is caring for a client with a history of an abdominal aortic aneurysm (AAA). Which of the following assessments should be the nurse's priority for a client with an abdominal aortic aneurysm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client post-transcatheter aortic valve replacement (TAVR). During the first cardiac rehabilitation session, the client tells the nurse, "I do not need to be here. I am feeling so much better, I can do this at home." Which of the following is the appropriate nursing response?

Correct Answer is B

Explanation

A nurse is caring for a client diagnosed with atrial fibrillation who is receiving continuous IV heparin. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

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