The nurse is teaching a patient with an abdominal aortic aneurysm (AAA) about activity. Which statement made by the patient indicates an understanding of the teaching?

I will walk 20 minutes every other day.

Instead of taking my car, I will ride my bike everywhere.

I am starting back to work as a grocery store stocker next week.

I am going to continue my marathon training tomorrow.

Answer and Explanation

The Correct Answer is A

A. I will walk 20 minutes every other day: This is correct. Walking is a safe, low-impact activity that promotes cardiovascular health without placing undue stress on the abdominal area, which is important for a patient with an AAA.
B. Instead of taking my car, I will ride my bike everywhere: Biking can be too strenuous and risky for someone with an AAA, as it may involve physical exertion and potential for trauma to the abdominal area.
C. I am starting back to work as a grocery store stocker next week: This job likely involves heavy lifting and significant physical activity, which is contraindicated for a patient with an AAA due to the risk of increased intra-abdominal pressure and potential aneurysm rupture.
D. I am going to continue my marathon training tomorrow: Marathon training is highly strenuous and can significantly increase blood pressure and stress on the abdominal region, posing a high risk of aneurysm rupture.

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Correct Answer is B

Explanation

A. Increase the client's oral fluid intake.: While staying hydrated is generally good, it doesn't directly address the issue of cold feet caused by reduced circulation.
B. Obtain a pair of slipper socks for the client.: Slipper socks can help keep the feet warm without constricting blood flow, which is important for comfort and promoting circulation.
C. Rub the client's feet briskly for several minutes.: Vigorous rubbing could potentially cause injury or worsen circulation issues due to the fragility of the tissues in vascular compromise.
D. Place a moist heating pad under the client's feet.: Moist heat is not recommended as it can increase the risk of burns and injury, especially if the client has reduced sensation due to vascular occlusion.

A. Obtain an electrocardiogram (ECG) exam B. Obtain intravenous access C. Administer 2 L of oxygen per nasal cannula D. Obtain a rectal temperature

Correct Answer is C

Explanation

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

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The nurse is teaching a patient with an abdominal aortic aneurysm (AAA) about activity. Which statement made by the patient indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Correct Answer is B

Explanation

The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Correct Answer is C

Explanation

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