aortic aneu

17. Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Assess the abdominal incision for redness. d. Counsel the patient to plan for a long recovery time.

ANS: B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.

22. An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first? a. Draw blood for laboratory testing. b. Check the patient's blood pressure. c. Assess the patient for an abdominal bruit. d. Determine any family history of heart disease.

ANS: B Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately

2. Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm? a. Low back pain b. Difficulty swallowing c. Abdominal tenderness d. Changes in bowel habits

ANS: B Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms would be expected in patients with abdominal aortic aneurysms

1. Which risk factor would the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm? a. Male gender b. Hypertension c. Age over 60 years d. Family history of vascular disease

ANS: B Hypertension can potentially be managed to decrease the patient's risk for further expansion of the aneurysm. Male gender, older age, and family history are not modifiable risk factors.

24. The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action would the nurse take first? a. Wrap both legs in a warming blanket. b. Notify the surgeon and anesthesiologist. c. Document the findings and recheck in 15 minutes. d. Review the preoperative assessment in the health record.

ANS: B Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings would be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse already would know whether pulses were present before surgery. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient's legs.

23. After receiving a change-of-shift report, which patient admitted to the emergency department would the nurse assess first? a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools

ANS: B The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain.

25. When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation

ANS: C Loose, bloody (maroon-colored) stools at this time may indicate intestinal ischemia or infarction and would be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.

31. The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure of 148/88 mm Hg d. 25 mL of urine output over the past hour

ANS: C The systolic blood pressure is typically kept between 100- and 110-mmHg to minimize extension of the dissection. The nurse will need to notify the health care provider so that b-blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and would also be reported but do not require immediate action.

30. Which intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously could the nurse delegate to assistive personnel (AP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

ANS: D Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement would be done by RNs