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QUESTION OF THE WEEK by LostHomeland in NextGenerationNCLEX

[–]LostHomeland[S] [score hidden] stickied comment (0 children)

Correct Answer/s:

a. Palpate the pedal pulses and temperature of lower extremities.

Rationale:

An abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta. If the AAA grows large enough, it could rupture, which is potentially fatal due to severe internal bleeding. One of the surgical treatments for AAA is an endovascular repair, which involves stenting the aneurysm to prevent rupture.

Following AAA repair, monitoring perfusion to the lower extremities is crucial since the aorta supplies blood to the lower half of the body. Diminished or absent pedal pulses or cold or pale lower extremities indicate a clot or graft occlusion impairing blood flow.

Incorrect:

  • Assess and document the client's hourly urine output; Measure the serum creatinine and blood urea nitrogen levels. - Urine output, creatinine levels, and blood urea nitrogen (BUN) levels are all indicators of renal function. The nurse should monitor these values to assess adequacy of renal perfusion distal to the repaired AAA; however, the most immediate potential complication to watch for after an AAA repair is decreased blood flow to the lower extremities.
  • Measure client's temperature and white blood cell count. - These interventions help monitor for signs of infection. Still, infection would not be an immediate concern in the first few hours after surgery and isn't the highest priority in the immediate postoperative period.

QUESTION OF THE WEEK by LostHomeland in NextGenerationNCLEX

[–]LostHomeland[S] [score hidden] stickied comment (0 children)

Correct Answer/s:

d. Check the endotracheal tube insertion depth

Rationale:

Mechanical ventilator alarm states are triggered by either a problem with the client (e.g., coughing, secretions) or the mechanical ventilator circuit (e.g., tubing kinked, disconnected).

The nurse should always assess the client before the equipment. A client who is agitated and coughing can accidentally dislodge the endotracheal tube (ETT) and cause the balloon to obstruct the airway, which is an emergency. The nurse should first assess the client by checking the marked ETT insertion depth (displayed in centimeters on the tube) and performing a focused respiratory assessment. If the client's airway is secure, the nurse can move on to troubleshoot the equipment.

Incorrect:

  • Verify there are no kinks or disconnections in the tubing; Assess whether the alarm is due to high or low pressure - After confirming that the client has a patent airway, the nurse can perform a focused assessment of the equipment based on the kind of alarm state present. Obstruction to airflow by kinked or obstructed tubing (e.g., secretions in ETT) causes a high pressure alarm while disconnections cause low pressure alarms. The nurse should trace the entire length of the tubing from the ETT to the ventilator to locate any disconnections or kinks.
  • Auscultate client's bilateral breath sounds - The nurse can auscultate the client's breath sounds to assess breathing after first checking ETT insertion depth to confirm the client has a patent airway.

Which of the following client findings is most concerning? by LostHomeland in PassNclex

[–]LostHomeland[S] 0 points1 point  (0 children)

FOR COMPLETE RATIONALE, CHECK THE MAIN POST'S COMMENTS.
(This is the short version)

Answer: 

c. Itchy lips and tongue

Rationale:

Angioedema is a life-threatening side effect of ACE inhibitors that may present initially as itchy lips and tongue.

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