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 A

Explanation

The best response by the nurse would be to explain that no food or drink is allowed for 4 hours before the stress test.

The reason for this restriction is that consuming food or drink can affect the accuracy of the cardiac stress test results. Eating or drinking can increase heart rate and blood pressure, potentially altering the test's interpretation. It is important for the client to have an empty stomach to ensure accurate test results.

Let's review the other options and explain why they are not the best responses:

Asking the client's visitor to bring some coffee from the cafeteria for the client: This option goes against the restriction of no food or drink before the stress test. It is important to adhere to the guidelines provided to ensure accurate test results.

Making up a small breakfast tray from what is available on the unit: Similarly, providing breakfast to the client goes against the restriction of no food before the stress test. The client should have an empty stomach for the test.

Offering hot tea or coffee only: While hot tea or coffee might be tempting for the client, it still violates the requirement of no food or drink before the stress test. The client should only be allowed to consume water during the fasting period.

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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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 scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

Correct Answer is A

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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