The nurse is caring for a client diagnosed with an abdominal aortic aneurysm (AAA). Which of the client's vital signs will be a priority for the nurse to monitor?
Core temperature
Blood pressure
Pulse rate
Respiratory rate
The Correct Answer is B
Choice A Reason:
Core temperature is important to monitor in many clinical situations, but it is not the primary concern for a client with an abdominal aortic aneurysm. While fever can indicate infection, which is a potential complication, it is not directly related to the immediate risks associated with AAA.
Choice B Reason:
Blood pressure is the most critical vital sign to monitor in a client with an abdominal aortic aneurysm. Elevated blood pressure can increase the risk of aneurysm rupture, which is a life-threatening emergency. Maintaining blood pressure within a safe range is essential to prevent complications and ensure the stability of the aneurysm.
Choice C Reason:
Pulse rate is also important to monitor, but it is not as directly indicative of the risk of aneurysm rupture as blood pressure. While changes in pulse rate can signal cardiovascular stress or other issues, blood pressure provides more direct information about the forces acting on the aneurysm.
Choice D Reason:
Respiratory rate is a vital sign that can indicate respiratory distress or other systemic issues, but it is not the primary concern in the context of an abdominal aortic aneurysm. Blood pressure remains the most critical parameter to monitor to prevent rupture and manage the condition effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Neck vein distention is a common finding in patients with mitral valve insufficiency. This condition leads to increased pressure in the left atrium, which can back up into the pulmonary veins and subsequently the right side of the heart, causing jugular venous distention.
Choice B Reason:
Splenomegaly is not typically associated with mitral valve insufficiency. It is more commonly seen in conditions like liver disease, hematologic disorders, and infections. Mitral valve insufficiency primarily affects the heart and lungs rather than the spleen.
Choice C Reason:
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not a common finding in mitral valve insufficiency. Petechiae are more often associated with conditions that affect platelet function or coagulation, such as thrombocytopenia or vasculitis.
Choice D Reason:
An S4 heart sound, also known as an atrial gallop, can be heard in patients with mitral valve insufficiency. This sound occurs due to the atria contracting forcefully to overcome a stiff or hypertrophic ventricle, which is often a result of chronic pressure overload from the regurgitant flow.
Correct Answer is C
Explanation
Choice A: Administer intravenous pain medication
Administering intravenous pain medication is crucial for managing pain in burn patients. Pain management is essential to ensure the patient's comfort and to prevent complications such as shock. However, while important, it is not the immediate priority in this scenario. The primary concern should be assessing and securing the airway, especially given the location of the burns on the face and chest, which could indicate potential inhalation injuries.
Choice B: Draw blood for a complete blood cell (CBC) count
Drawing blood for a CBC count is important for assessing the patient's overall health and identifying any potential complications such as infection or anemia. However, this action is not the immediate priority. The nurse must first ensure that the patient's airway is clear and that there are no life-threatening conditions that need immediate attention.
Choice C: Inspect the mouth for signs of inhalation injuries
Inspecting the mouth for signs of inhalation injuries is the priority action. Burns to the face and chest can lead to inhalation injuries, which can cause airway obstruction and respiratory distress. Early identification and management of inhalation injuries are critical to prevent respiratory failure. Signs of inhalation injury may include soot around the mouth or nose, singed nasal hairs, and difficulty breathing. Ensuring the airway is clear and managing any inhalation injuries takes precedence over other actions.
Choice D: Insert an indwelling urinary catheter
Inserting an indwelling urinary catheter can be important for monitoring urine output, which is a key indicator of renal function and fluid balance in burn patients. However, this action is not the immediate priority. The nurse must first address any potential airway issues before proceeding with other interventions.
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