The nurse is discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which information should the nurse include in the teaching?

Notify HCP of any redness or irritation of incision.

Do not lift anything more than 20 pounds.

Inform client that there may be pain not relieved with pain medication.

Stress the importance of having daily bowel movements.

Answer and Explanation

Correct Answer : A,B,C,D

The information that the nurse should include in the discharge teaching for the client who is three days post-operative abdominal aortic aneurysm repair is as follows:

Notify the healthcare provider (HCP) of any redness or irritation of the incision: This is important because redness or irritation can be signs of infection or other complications at the surgical site. Prompt reporting allows for early intervention and management.

Do not lift anything more than 20 pounds: Following abdominal aortic aneurysm repair, it is crucial to avoid heavy lifting or straining as it can put excessive pressure on the surgical site and potentially lead to complications such as incisional hernia. Restricting lifting to no more than 20 pounds helps to protect the incision and promote proper healing.

Inform the client that there may be pain not relieved with pain medication: Pain management is an essential aspect of post-operative care. However, it is important for the client to understand that complete relief of pain may not always be achievable with pain medication alone. They should be aware that mild to moderate discomfort may persist during the healing process, but severe or worsening pain should be reported to the healthcare provider.

Stress the importance of having daily bowel movements: After abdominal surgery, it is common for bowel movements to be delayed due to factors such as anesthesia, reduced activity, and pain medication. However, it is crucial for the client to maintain regular bowel movements to prevent constipation and potential complications such as bowel obstruction. The nurse should provide guidance on strategies to promote regular bowel function, such as staying hydrated, eating a balanced diet rich in fiber, and using stool softeners or gentle laxatives as directed by the healthcare provider.

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Correct Answer is ["D","E"]

Explanation

The traces that should require immediate follow-up by the nurse are:

● Pacer spikes occur directly before the T waves.

Pacer spikes occurring on the T waves indicate an issue with the pacemaker's timing or sensing. This could lead to inappropriate pacing or pacing during the refractory period, which can be detrimental to the client's heart function.

● The heart rate is outside of programmed parameters.

If the heart rate is outside of the programmed parameters set for the client's pacemaker, it may indicate a malfunction or failure of the device or a change in the client's cardiac status. It is important for the nurse to assess the client's condition and notify the healthcare provider for further evaluation and intervention.

Let's review the other options and explain why they do not require immediate follow-up:

Pacer spikes are adequate in number: This indicates that the pacemaker is delivering the appropriate number of electrical impulses as programmed. As long as the other parameters are normal, this finding does not require immediate follow-up.

Pacer spikes occur directly before the P waves: This is the desired and expected pattern for a pacemaker in normal sinus rhythm. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

Pacer spikes occur directly before the QRS waves: This is also the desired and expected pattern for a pacemaker in clients with ventricular pacing. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

The heart rate is within programmed parameters: If the heart rate falls within the programmed parameters set for the client's pacemaker, it indicates that the device is functioning appropriately in maintaining the desired heart rate.

A. Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night. B. Use an automated noninvasive blood pressure machine to obtain frequent measurements. C. Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting. D. Assist the patient up in the chair for meals to avoid complications associated with immobility.

Correct Answer is B

Explanation

The action that will be included in the plan of care for a client in a hypertensive emergency receiving nifedipine is to use an automated noninvasive blood pressure machine to obtain frequent measurements.

In a hypertensive emergency, the client's blood pressure is severely elevated, requiring immediate treatment and close monitoring. Nifedipine is a calcium channel blocker commonly used to lower blood pressure in such situations. Continuous blood pressure monitoring is crucial to assess the effectiveness of the medication and ensure that the blood pressure is brought under control safely.

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night: While providing a conducive environment for sleep is important for overall patient well-being, in a hypertensive emergency, the priority is to manage and monitor the blood pressure. Sleep hygiene may not be the immediate concern in this situation.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting: NPO (nothing by mouth) orders are typically implemented when there is a risk of aspiration or pending a procedure requiring anesthesia. In a hypertensive emergency, the focus is on managing blood pressure and ensuring appropriate hydration and nutrition as needed. NPO status may not be necessary unless speciﬁcally indicated for the individual patient.

Assist the patient up in the chair for meals to avoid complications associated with immobility: While mobilization and preventing complications associated with immobility are important aspects of care, in a hypertensive emergency, the primary focus is on managing blood pressure and stabilizing the client's condition. Mobilization may be appropriate once the blood pressure is under control and the client's condition permits.

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The nurse is discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply

Correct Answer is ["D","E"]

Explanation

The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

Correct Answer is B

Explanation

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