The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

White blood cell count and pulse rate.

Hematocrit and blood pressure.

Calcium level and skin condition.

Serum amylase and level of consciousness.

Answer and Explanation

The Correct Answer is B

Choice A reason: White blood cell count and pulse rate are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. White blood cell count is a measure of the immune system activity, and it may be elevated in cases of infection or inflammation, but it is not specific to AAA. Pulse rate is a measure of the heart rate, and it may be increased in cases of anxiety, pain, or shock, but it is not indicative of AAA.

Choice B reason: Hematocrit and blood pressure are the most important information about the client that the nurse should tell the healthcare provider, because they are directly related to the AAA and the low back pain. Hematocrit is a measure of the percentage of red blood cells in the blood, and it may be decreased in cases of bleeding or anemia, which can occur if the AAA ruptures or leaks. Blood pressure is a measure of the force of the blood against the walls of the arteries, and it may be increased in cases of hypertension or stress, which can worsen the AAA or cause it to rupture. The nurse should monitor the client's hematocrit and blood pressure closely and report any changes to the healthcare provider.

Choice C reason: Calcium level and skin condition are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Calcium level is a measure of the amount of calcium in the blood, and it may be abnormal in cases of bone disorders, kidney disorders, or parathyroid disorders, but it is not relevant to AAA. Skin condition is a general term that can describe the appearance, texture, color, or temperature of the skin, and it may be altered in cases of infection, allergy, or injury, but it is not specific to AAA.

Choice D reason: Serum amylase and level of consciousness are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Serum amylase is a measure of the amount of amylase, an enzyme that digests starch, in the blood, and it may be elevated in cases of pancreatitis, gallstones, or intestinal obstruction, but it is not associated with AAA. Level of consciousness is a measure of the client's mental status, alertness, and responsiveness, and it may be impaired in cases of brain injury, stroke, or coma, but it is not indicative of AAA.

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Correct Answer is B

Explanation

Choice A reason: Wearing clothing to cover the radiation site is a correct action, as it can protect the skin from sun exposure, irritation, and infection. The clothing should be loose-fitting, soft, and made of natural fibers, such as cotton or linen. The clothing should also be changed daily and washed separately from other clothes.

Choice B reason: Washing the radiation site with antibacterial soap and water is an incorrect action, as it can dry out, damage, or inflame the skin. The skin in the radiation site is more sensitive and vulnerable to injury and infection. The client should use mild, unscented soap and water to gently cleanse the area once a day, and avoid rubbing or scrubbing the skin.

Choice C reason: Applying prescribed lotions to the radiation site is a correct action, as it can moisturize, soothe, and heal the skin. The client should use only the lotions that are recommended by the health care provider, and avoid any products that contain alcohol, perfume, or other irritants. The client should also apply the lotions at least one hour before or after the radiation treatment, and not during the treatment.

Choice D reason: Drying the area with patting motions after taking a shower is a correct action, as it can prevent friction and trauma to the skin. The client should use a soft, clean towel to gently pat the skin dry, and avoid rubbing or pulling the skin. The client should also avoid using hair dryers, heating pads, or ice packs on the radiation site.

A. Log roll the client and place adult disposable briefs beneath the client. B. Maintain traction while the client uses a urinal. C. Release the traction so the client can use a bedpan. D. Insert an indwelling urinary catheter preoperatively.

Correct Answer is B

Explanation

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

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The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

Nursing Test Bank

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