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.

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Correct Answer is D

Explanation

Sinus bradycardia with a heart rate of 32 beats/min and accompanying hypotension and symptoms of feeling faint indicates significant hemodynamic compromise. In such cases, the first-line intervention is to provide external cardiac pacing through transcutaneous pacemaker (TCP) pads. TCP can help increase the heart rate and improve cardiac output by delivering electrical impulses to the heart.

Administering the scheduled dose of diltiazem (Cardizem), a calcium channel blocker, is not appropriate in this situation. Diltiazem can further lower the heart rate and blood pressure, exacerbating the client's symptoms and potentially leading to adverse effects.

Repositioning the patient on the left side or having the patient perform the Valsalva maneuver are not effective interventions for treating sinus bradycardia with hemodynamic compromise. These actions may be used in specific situations, but in this case, the client requires immediate intervention to address the low heart rate and blood pressure.

A. Assess pulse of affected extremity every 15 minutes at ﬁrst. B. Palpate the affected leg for pain during every assessment C. Assess the client for signs and symptoms of compartment syndrome every 2 hours. D. Perform Doppler evaluation once daily.

Correct Answer is ["A","B","C","D"]

Explanation

Assess pulse of the affected extremity every 15 minutes at ﬁrst: Frequent assessment of the pulse in the affected extremity is important to monitor for any changes in blood ﬂow. This allows the nurse to identify any potential complications such as graft occlusion or compromised circulation promptly.

Palpate the affected leg for pain during every assessment: Assessing for pain in the affected leg is crucial to identify any signs of ischemia or inadequate perfusion. Increased pain could indicate reduced blood ﬂow or other complications that require immediate attention.

Assess the client for signs and symptoms of compartment syndrome every 2 hours: Compartment syndrome can occur after vascular surgeries, and early recognition is vital. The nurse should assess for signs and symptoms such as pain, numbness, tingling, increased swelling, and tense compartments. Regular assessment every 2 hours can help detect compartment syndrome promptly and prevent further complications.

Perform Doppler evaluation once daily: Doppler evaluation may be ordered by the healthcare provider to assess blood ﬂow and graft patency. However, the frequency of Doppler evaluation may vary depending on the client's condition and the healthcare provider's orders. Once daily assessment is not suﬃcient if there are concerns regarding blood ﬂow or graft viability.

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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 nurse is caring for a client with sinus bradycardia at a rate of 32 beats/min, blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which is the appropriate action?

Correct Answer is D

Explanation

A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

Correct Answer is ["A","B","C","D"]

Explanation

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