Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair?

Absent bilateral pedal pulses.

Complaints of pain at the site of the incision.

Distended, tender abdomen.

An elevated temperature of 100 F

Answer and Explanation

The Correct Answer is A

Absent bilateral pedal pulses indicate a potential vascular complication, such as impaired circulation or blood flow to the lower extremities. It may suggest compromised perfusion and could be a sign of arterial occlusion or thrombosis, which requires immediate intervention. The nurse should notify the healthcare provider promptly to assess the client's condition and initiate appropriate interventions to restore circulation to the lower extremities.

While complaints of pain at the site of the incision are significant, post-operative pain is expected after abdominal surgery. The nurse should assess the pain and provide appropriate pain management interventions, but it may not require immediate intervention unless the pain is severe or accompanied by other concerning symptoms.

A distended, tender abdomen could indicate various post-operative complications, such as bowel obstruction or peritonitis. Although it should be evaluated and reported to the healthcare provider, it may not require immediate intervention unless the client's condition deteriorates or other signs of a surgical emergency are present.

An elevated temperature of 100°F (37.8°C) alone, without other signs of infection or systemic complications, may not necessarily require immediate intervention. It could be a normal response to surgery or a mild post-operative infection. The nurse should monitor the client's temperature and assess for other signs of infection, and if necessary, report it to the healthcare provider for further evaluation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Abdominal aortic aneurysms (AAA) often do not present with speciﬁc symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common ﬁnding during the assessment of a client with an abdominal aortic aneurysm.

Let's brieﬂy review the other statements:

"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reﬂux rather than speciﬁcally related to an abdominal aortic aneurysm.

"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.

"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reﬂux or gastroesophageal reﬂux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.

A. The client reports a headache with pain at level 5 of 10 B. The client has epistaxis after blowing his nose several times C. The client has a urine output of 120 mL over a 4 hours D. The client has a new-onset blurry vision and facial asymmetry

Correct Answer is D

Explanation

The client reports a headache with pain at level 5 of 10.: While a headache can be a symptom of high blood pressure, a pain level of 5 out of 10 alone does not indicate an immediate life-threatening condition. It is important to assess and manage the client's pain, but it may not be the most critical ﬁnding to report in this situation.

The client has epistaxis after blowing his nose several times. : Epistaxis, or a nosebleed, can occur due to high blood pressure, but it is not the most urgent or critical symptom in a hypertensive emergency. While it is essential to address the nosebleed and monitor blood pressure, other symptoms may indicate more severe consequences of uncontrolled high blood pressure.

The client has a urine output of 120 mL over 4 hours.: While decreased urine output can be a concerning sign, it is not the most signiﬁcant ﬁnding to report in a hypertensive emergency. In this scenario, the focus is on acute complications related to high blood pressure, such as organ damage or impending stroke, which require immediate attention.

In summary, the ﬁnding that is most important to report to the healthcare provider in a client with a hypertensive emergency is the presence of new-onset blurry vision and facial asymmetry. These symptoms suggest potential neurological involvement and the need for urgent medical intervention to prevent serious complications like stroke.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?

Correct Answer is B

Explanation

The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

Correct Answer is D

Explanation

The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement?

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

A nurse is teaching a client with chronic peripheral artery disease. What client statement indicates the need for further teaching?

The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a client with hypertension who has a new prescription for enalapril (Vasotec). Which statement of the nurse to the patient would require the charge nurse's intervention?

The nurse is reviewing the medical records of a client with atrial fibrillation. Which prescription should the nurse question?