The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

monitoring for dysrhythmias

monitoring for bleeding.

adherence to their antihypertensive drugs

preventing thrombus formation.

Answer and Explanation

The Correct Answer is C

A. Monitoring for dysrhythmias
While cardiovascular health is important, dysrhythmias are not a primary concern in a small abdominal aortic aneurysm.

B. Monitoring for bleeding
While aneurysms can rupture, a small aneurysm is managed medically with blood pressure control, making bleeding less of an immediate concern.

C. Adherence to their antihypertensive drugs
Hypertension increases pressure on the aneurysm, increasing the risk of expansion and rupture. Strict adherence to antihypertensive medications is essential for preventing complications.

D. Preventing thrombus formation
While thrombus formation can occur in large aneurysms, it is not the primary focus in a small, medically managed aneurysm.

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Correct Answer is D

Explanation

A. includes the head-to-toe anterior and posterior assessment.
This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.

B. priorities are continuing and ongoing but treatment will be deferred if the client is unstable.
In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.

C. is focused on airway maintenance and ventilation effectiveness.
As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.

D. focuses on the ABCDs of the client to identify life-threatening problems.
The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).

A. Continue to monitor the client as a paralytic ileus is possible B. Administer the PRN stool softener to the client C. Obtain an order to insert a nasogastric tube set to low suction D. Report the assessment findings to the surgeon

Correct Answer is D

Explanation

A. Continue to monitor the client as a paralytic ileus is possible

Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.

B. Administer the PRN stool softener to the client

A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.

C. Obtain an order to insert a nasogastric tube set to low suction

An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.

D. Report the assessment findings to the surgeon

Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.

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The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

Correct Answer is D

Explanation

The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

Correct Answer is D

Explanation

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