Question 1 See full question 13s
A client displays signs associated with a possible ruptured aortic aneurysm. What is
the priority nursing intervention?
You Selected:
• Prepare the client for surgical intervention
C
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Question 1 See full question 13s
A client displays signs associated with a possible ruptured aortic aneurysm. What is
the priority nursing intervention?
You Selected:
• Prepare the client for surgical intervention
Correct response:
• Prepare the client for surgical intervention
Explanation:
When the vessel ruptures, prompt surgery is required for it’s repair.
Antihypertensive medications and beta-adrenergic blockers can help control
hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used
to detect an aneurysm.
Remediation:
• Aneurysm (thoracic aortic)
Question 2 See full question 45s
After undergoing a cardiac catheterization, a client has a large puddle of blood
under his buttocks. What is the nurse’s priority action?
You Selected:
• Assess the groin site
Correct response:
• Assess the groin site
Explanation:Assessment of the groin site is the priority. This establishes the source of the blood,
and determines how much blood has been lost. The goal is to stop the bleeding.
The nurse would call for help if needed after the assessment of the situation. After
determining the extent of the bleeding, vital sign assessment is important. The
nurse should never move the client, in case a clot has formed. Moving can disturb
the clot and cause re-bleeding.
Remediation:
• Cardiac catheterization
Question 3 See full question 33s
The nurse is ambulating a client. The client experiences chest pain after ambulating
50 feet. What is the nurse’s priority intervention?
You Selected:
• Sit the client down
Correct response:
• Sit the client down
Explanation:
The priority is to decrease oxygen consumption by sitting this client down. When
the client’s condition is stabilized, he can be returned to bed. An ECG can be
obtained after the client is sitting down, and the ordered sublingual nitroglycerin
could be administered.
Remediation:
• Ambulation, progressive
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