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. Which of the following is NOT one of the major duties of the M6 practical nurse?

Correct answer: D

Rationale: The correct answer is D because implementing Level II through Level IV CSH operations is not a major duty of the M6 practical nurse. A practical nurse's major duties include performing preventive, therapeutic, and emergency nursing care procedures (Choice A), managing other paraprofessional personnel (Choice B), and managing ward or unit operations (Choice C). These duties are more aligned with the responsibilities of a practical nurse, emphasizing patient care and coordination within a healthcare setting.

3. Which of the following statements about medications is true?

Correct answer: C

Rationale: The correct answer is C. This statement is true because both prescription medications and over-the-counter medications, along with herbal remedies, can interact with food. Choice A is incorrect because over-the-counter medications can also interact with food or nutrients. Choice B is incorrect as not all prescription medications have significant interactions with food. Choice D is misleading because herbal products are not always safe, as they can have side effects and interact with other medications.

4. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

Correct answer: D

Rationale: The correct interventions for a client presenting with acute epigastric pain and vomiting bright red blood are to assess the client’s vital signs and start an IV with an 18-gauge needle. Assessing vital signs helps in determining the client's current condition and response to treatment, while starting an IV is crucial for administering medications and fluids. Beginning iced saline lavage is not appropriate in this situation as the priority is to stabilize the client and address potential bleeding. Therefore, options A and B are correct choices, making option D the most appropriate answer.

5. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

Correct answer: A

Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.

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