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 C

Explanation

A. Hypernatremia is incorrect. Furosemide can cause hyponatremia rather than hypernatremia due to increased sodium excretion.
B. Hypocalcemia is incorrect. While loop diuretics can cause some calcium loss, hypocalcemia is less common than hypokalemia.
C. Hypokalemia is correct. Furosemide is a loop diuretic that increases potassium excretion, leading to a risk of hypokalemia, which can cause muscle weakness, arrhythmias, and other complications.
D. Hyperkalemia is incorrect. Furosemide promotes potassium excretion, making hyperkalemia unlikely.

A. Increased appetite B. Distended neck veins C. Worsening lower extremity edema D. Feeling fatigued E. Unable to lie flat F. Weight gain >2 lb in 24 hours

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Increased appetite is not a symptom of worsening right-sided heart failure; clients may actually experience nausea or anorexia due to fluid congestion in the gastrointestinal system.
B. Distended neck veins (jugular venous distension) indicate increased venous pressure and systemic congestion, which are signs of worsening right-sided heart failure.
C. Worsening lower extremity edema occurs due to fluid retention and poor venous return, which are hallmark signs of right-sided heart failure.
D. Feeling fatigued is common as the heart struggles to pump blood effectively, leading to decreased oxygen delivery to tissues.
E. Unable to lie flat (orthopnea) is typically associated with left-sided heart failure but can also occur in right-sided failure due to fluid overload and pulmonary congestion.
F. Weight gain >2 lb in 24 hours suggests significant fluid retention and worsening heart failure, requiring prompt medical attention.

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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 with heart failure who takes furosemide (Lasix) 20 mg daily at home and is receiving 40 mg of furosemide (Lasix) IV daily in the hospital. The nurse is aware that this patient is at risk for which electrolyte imbalance?

Correct Answer is C

Explanation

A nurse is caring for a client with right-sided heart failure. Which of the following symptoms should the nurse include in teaching the client about signs of worsening heart failure? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D","E","F"]

Explanation

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