Descending aortic aneurysm repair
The nurse is caring for a client on the first day of postoperative for a descending aortic aneurysm repair. Which assessment finding should the nurse prioritize reporting to the healthcare provider?
a.Serum potassium 4.8
b.Urine output 30ml/hr
c. Electrocardiogram ST Segment elevation
d.BP 130/80
21. A client who is admitted to the intensive care unit is manifesting signs of an acute Addisonian crisis. The nurse is observing the clients, a hemodynamic monitor, as the client becomes tachycardic and hypotensive. Which intervention is most important for the nurse to implement?
a.Access invasive lines using sterile gloves and sterile transport dressing
b.Administer all dietary supplements with meals
c. Perform passive exercises and ROM
d.Notify HCP of cardiac output less the 3.9
24. When assessing an adult client on a mechanical ventilator, the nurse notes that the client becomes restless has diminished to absent breath sounds on the right side and the right side of the clients chest is not expanding equally to the left side. Based on these assessment findings, which analysis should the nurse formulate?
a.The endotracheal tube has slipped into the esophagus
b.A tension pneumothorax has occurred.
c. The ventilator is malfunctioning
d.The client developed pneumonia
25. An adult client is transported via ambulance to the emergency department following a motorvehicle accident . On arrival the client complains of severe upper back pain. The vital signs are: Temp 98.6, HR 145 bpm, resp 26 and BP 70/40. Which change in assessment findings indicate the clients condition is deteriorating?
a.Oxygen sat 90%
b.Glascow coma score 15
c. HR 40 bpm
d.Resp 34 breaths/min
27. Following a CABG, an older client with COPD is being maintained on mechanical ventilation. Which action should the nurse implement to prevent ventilator-associated pneumonia?
a.Maintain the head of the bed at 45 degree elevation
b.Instill sterile saline in endotracheal tube before suctioning
c. Schedule q4 hour bronchodilator nebulizer treatment
d.Set FIO2 to deliver 100% oxygen concentration
28. The nurse assess a male client postoperatively who has an arterial line in the radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client’s right-hand fingers. What action should the nurse plan?
a.Elevate the clients right arm
b.Perform allen test
c. Flush the line with heparinized saline
d.Notify HCP
Note:- Please give short explanation/rational why the answer is correct
