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 D

Explanation

A. Instruct the client to avoid foods with gluten, such as wheat bread.
While some individuals with Crohn's disease may experience improvement by avoiding certain types of carbohydrates, including gluten, this recommendation is not universally applicable to all individuals with Crohn's disease. Gluten restriction is more relevant for those with gluten sensitivity or celiac disease.

B. Explain that the need to restrict fluids is the primary limitation.
This statement is not accurate. Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease. In fact, maintaining adequate hydration is generally important for overall health. Restricting fluids is not a standard dietary recommendation for managing Crohn's disease.

C. Advise the client to limit foods that are high in calcium and iron.
Limiting foods high in calcium and iron is not a standard recommendation for Crohn's disease. In fact, adequate intake of essential nutrients, including calcium and iron, is important for overall health. Limiting these nutrients could lead to nutritional deficiencies.

D. Describe the use of an elimination diet to find trigger foods.
This is the most appropriate response. Crohn's disease symptoms can vary among individuals, and identifying trigger foods through an elimination diet can help personalize dietary recommendations. By systematically eliminating and reintroducing foods, individuals can identify which specific foods may exacerbate their symptoms.

A. Assess client for signs and symptoms of upper airway infection. B. Determine if the client is using an inhaler before exercising. C. Teach client to use pursed lip breathing when episodes occur. D. Review the client's routine asthma management prescriptions

Correct Answer is D

Explanation

A. Assess client for signs and symptoms of upper airway infection:
While upper airway infections can contribute to respiratory symptoms, the client's history of asthma and the exacerbation of symptoms during exercise suggest that asthma management should be a priority.

B. Determine if the client is using an inhaler before exercising:
This is a relevant consideration, and ensuring proper pre-exercise use of bronchodilators (such as an inhaler) is an important aspect of asthma management. However, the question is broader and involves a review of the client's overall asthma management.

C. Teach client to use pursed lip breathing when episodes occur:
Pursed lip breathing is a technique that can help manage symptoms, especially during episodes of bronchoconstriction. However, the focus here is on a more comprehensive assessment and review of the client's routine asthma management.

D. Review the client's routine asthma management prescriptions:
This is the correct answer. The client's reported symptoms during exercise suggest a potential need for adjustments to the routine asthma management plan. Reviewing the client's prescriptions, including the type and timing of medications, can help ensure optimal control of symptoms, especially during physical activity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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