Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Elevate extremities on pillows.

Evaluate edema for pitting.

Wrap the feet with warmed blankets.

Assess pulses with a vascular Doppler

Answer and Explanation

The Correct Answer is D

A. Elevate extremities on pillows:
While elevation can be beneficial for reducing dependent edema, the priority is to assess the pulses first to determine the adequacy of peripheral perfusion.

B. Evaluate edema for pitting:
Assessing edema for pitting is important for gathering additional information, but it is not the initial action in this scenario. Assessing pulses is more critical to evaluate perfusion.

C. Wrap the feet with warmed blankets:
Warming the feet with blankets may be appropriate in some situations, but it is not the priority when the client is exhibiting edema and non-palpable pedal pulses. The primary concern is assessing perfusion.

D. Assess pulses with a vascular Doppler:
This is the correct action. The non-palpable pedal pulses are concerning and require immediate assessment to determine the status of peripheral perfusion. Using a vascular Doppler will help the nurse assess the presence or absence of blood flow in the lower extremities.

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Correct Answer is B

Explanation

A. Administer intravenous fluid bolus as prescribed by the healthcare provider.
While hydration is important, the vital signs provided (elevated heart rate and respiratory rate) are more indicative of potential respiratory distress. Administering fluids may be indicated in certain situations, but it may not address the immediate concern of compromised oxygenation.

B. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
This is the correct choice. The client's elevated heart rate and respiratory rate suggest the need for improved oxygenation. Applying oxygen at a high flow rate via a non-rebreather mask is an immediate intervention to address potential respiratory compromise. Monitoring the pulse oximeter provides real-time feedback on oxygen saturation.

C. Medicate for pain and monitor vital signs according to protocol.
Pain management is an important aspect of post-operative care, but the immediate concern in this scenario is the potential for respiratory distress. Administering pain medication alone may not address the primary issue.

D. Encourage the client to splint the incision with a pillow to cough and deep breathe.
While encouraging the client to cough and deep breathe is important for post-thoracotomy care, the elevated vital signs suggest a need for more immediate intervention to ensure adequate oxygenation. Applying oxygen and monitoring the pulse oximeter take precedence.

A. Administer a topical analgesic. B. Cleanse the mouth with swabs C. Obtain a soft diet for the client. D. Encourage frequent mouth care

Correct Answer is D

Explanation

A. Administer a topical analgesic:
Administering a topical analgesic can help alleviate pain and discomfort associated with oral thrush. However, it addresses the symptom rather than the cause of the issue.

B. Cleanse the mouth with swabs:
Cleansing the mouth with swabs can be part of the care plan for managing oral thrush. It helps remove debris and may reduce the fungal load in the mouth.

C. Obtain a soft diet for the client:
Providing a soft diet is important for clients with oral thrush as it minimizes irritation to the affected area. However, it may not be the first intervention; rather, it is part of the overall care plan.

D. Encourage frequent mouth care:
Encouraging the client to perform frequent mouth care is the most immediate and direct intervention. This includes gentle rinsing with a mild solution, which can help relieve symptoms and prevent the spread of the infection.

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Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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