A nurse is caring for a client who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The client has developed coolness of the extremities and complains of a bloated feeling in the abdomen. What would be the nurse's best action?
A. Measure the abdominal girth and check pulses.
B. Raise the head of the bed to 90 degrees.
C. Measure the cardiac output.
D. Irrigate the Foley catheter.
A
Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue color in the flanks, and severe pain.
You might also like to view...
A client who presents in the psychiatric unit tells the admitting nurse that he or she is very depressed and is having a hard time staying clean and sober. Which of the following describes the psychobiology of his or her illness?
1. Depression or other mental illness should be treated with compatible medications. 2. Depression or other mental illnesses are symptoms of the substance abuse. 3. There is heritability and predisposition to alcohol dependence as well as complex environmental influences. 4. Depression or other mental illnesses is an expected outcome of substance abuse recovery.
A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?
A) Perform mechanical débridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.
A client's family insists that the client live with one of the family members permanently because of a shuffling gait, but the client refuses. Which approach is most effective to provide a safe en-vironment while also acting as a client advocate?
a. Teach the client to wear shoes with thin, firm soles. b. Explain community services for older clients. c. Help the client check the fit of his sneak-ers. d. Tell the client that he can do whatever he wants.
Which of the following variables makes some families more vulnerable to dysfunction than others in facing a particular crisis?
a. A family member's moving away b. Addition of a new family member c. Additional stressful events d. Previous experience with stressful events