the client is four 4 hours post operative abdominal aortic aneurysm repair which nursing intervention should be implemented for this client
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

Correct answer: B

Rationale: Assessing the client's bilateral pedal pulses is essential in this situation as it helps in evaluating the peripheral perfusion and circulation in the lower extremities. This assessment is crucial to detect any signs of decreased blood flow or complications, such as arterial occlusion or thrombosis. Ambulating the client may be important in the postoperative period, but assessing pedal pulses takes priority to ensure adequate perfusion. Maintaining continuous IV heparin drip is not typically indicated immediately post-operatively for an abdominal aortic aneurysm repair, as the risk of bleeding complications may outweigh the benefits. Providing a clear liquid diet is not a priority nursing intervention at this stage, as the focus should be on vascular assessment and postoperative monitoring.

2. For a patient on lithium therapy, which dietary recommendation is essential?

Correct answer: B

Rationale: The correct answer is to increase sodium intake. For patients on lithium therapy, maintaining consistent sodium intake is crucial to avoid fluctuations in drug levels. Increasing caffeine intake (choice A) is not recommended as it can interfere with lithium levels. While protein intake (choice C) is important for overall health, it is not specifically essential for patients on lithium therapy. Similarly, increasing fiber intake (choice D) is beneficial but not a primary concern for patients on lithium therapy.

3. In patients with heart failure, which type of diet is most recommended?

Correct answer: B

Rationale: A low-sodium diet is most recommended for patients with heart failure. This type of diet helps manage fluid retention by reducing the amount of sodium in the body, which in turn decreases the workload on the heart. High-sodium diets can lead to fluid retention and worsen heart failure symptoms. High-fat and low-carbohydrate diets are not specifically recommended for heart failure patients as the focus is primarily on controlling sodium intake.

4. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

Correct answer: D

Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.

5. What is the best position to measure the leg circumference of a client with bipedal edema?

Correct answer: A

Rationale: When measuring the leg circumference of a client with bipedal edema, the best position to ensure accurate and consistent measurements is the dorsal recumbent position. This position allows the legs to be comfortably positioned, with the individual lying on their back and legs extended. This facilitates accurate measurement of the circumference without the influence of gravity. Sitting and standing positions may not provide optimal conditions for accurate leg circumference measurements as they may not allow the legs to be fully extended. The supine position, although similar to dorsal recumbent, may not provide the same level of comfort and accuracy in leg circumference measurement for a client with bipedal edema.

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