CH 41: Aortic Aneurysms Flashcards
A 72-year-old male patient with a history of hypertension and smoking presents to the emergency department with complaints of deep, diffuse chest pain that extends to his back. His vital signs are BP 148/92 mmHg, HR 92 bpm, RR 18 breaths/min, and SpO₂ 97% on room air. A chest X-ray shows a widened mediastinum. Which diagnostic test would be most appropriate to confirm the suspected diagnosis?
A. Transthoracic echocardiogram
B. Computed tomography (CT) angiography
C. Chest X-ray with lateral view
D. Electrocardiogram (ECG)
B. Computed tomography (CT) angiography
Rationale: CT angiography is the gold standard for diagnosing aortic aneurysms because it provides detailed imaging of the aorta, allowing for precise measurement of the aneurysm’s size and location. It is the most reliable test for confirming the presence of a thoracic aortic aneurysm.
A patient is admitted to the ICU with a ruptured abdominal aortic aneurysm (AAA). Which of the following clinical findings would the nurse expect?
A. Hypotension
B. Severe back or abdominal pain
C. Distended, firm abdomen
D. Bradycardia
E. Weak or absent lower extremity pulses
A. Hypotension
B. Severe back or abdominal pain
C. Distended, firm abdomen
E. Weak or absent lower extremity pulses
Rationale: A ruptured AAA causes hypotension due to massive blood loss, severe back or abdominal pain from aneurysm rupture, a distended and firm abdomen due to internal bleeding, and weak or absent lower extremity pulses because of impaired blood flow.
The nurse is educating a patient newly diagnosed with a 5.2 cm abdominal aortic aneurysm (AAA). Which statement by the patient indicates a need for further teaching?
A. “I should quit smoking to prevent my aneurysm from growing larger.”
B. “Managing my blood pressure is important to reduce the risk of rupture.”
C. “Since my aneurysm is small, I don’t have to worry about follow-up scans.”
D. “If I experience sudden severe back or abdominal pain, I should seek emergency care.”
C. “Since my aneurysm is small, I don’t have to worry about follow-up scans.”
Rationale: A 5.2 cm AAA requires regular monitoring with ultrasound or CT scans every 6-12 months because the risk of rupture increases as the aneurysm enlarges. Follow-up imaging is essential to assess for expansion and determine the need for surgical intervention.
A nurse is preparing a patient with a 7.0 cm thoracic aortic aneurysm (TAA) for surgical repair. The provider orders esmolol (Brevibloc) infusion before surgery. What is the primary goal of administering this medication?
A. Reduce the risk of thrombus formation
B. Prevent vasospasm of the aorta
C. Increase cardiac output and perfusion
D. Decrease heart rate and blood pressure
D. Decrease heart rate and blood pressure
Rationale: Esmolol is a beta-blocker that reduces heart rate and blood pressure, minimizing shear stress on the aortic wall. This helps stabilize the aneurysm and lowers the risk of rupture before surgery.
A 68-year-old male with a history of hypertension, coronary artery disease, and tobacco use presents for a routine physical examination. A pulsatile mass is palpated in his periumbilical area, and an abdominal ultrasound confirms the presence of a 4.8 cm abdominal aortic aneurysm (AAA). Which risk factor is most important for the nurse to emphasize in patient education to slow the aneurysm’s progression?
A. Hypertension
B. Coronary artery disease
C. Tobacco use
D. Family history of aneurysms
C. Tobacco use
Rationale: Tobacco use is the most significant modifiable risk factor for aneurysm growth and rupture. Smoking contributes to arterial wall degeneration, increasing the risk of expansion. Smoking cessation is the most effective intervention to slow aneurysm progression.
A nurse is reviewing a patient’s history and identifies several risk factors for aortic aneurysms. Which of the following conditions increase the patient’s risk for developing an aortic aneurysm?
A. Hypertension
B. Ehlers-Danlos syndrome
C. Type 1 diabetes mellitus
D. Marfan syndrome
E. Lower extremity peripheral artery disease (PAD)
A. Hypertension
B. Ehlers-Danlos syndrome
D. Marfan syndrome
E. Lower extremity peripheral artery disease (PAD)
Rationale: Hypertension increases arterial wall stress, while Ehlers-Danlos syndrome and Marfan syndrome cause defects in collagen and elastin, weakening the aortic wall. Lower extremity PAD is associated with atherosclerosis, a major contributing factor to aneurysm formation.
The nurse is educating a patient with a strong family history of aortic aneurysms. The patient asks, “Does this mean I will definitely develop an aneurysm?” How should the nurse respond?
A. “Yes, genetic factors alone determine whether you will develop an aneurysm.”
B. “You are at increased risk, but managing modifiable risk factors can help reduce your chances.”
C. “Only congenital disorders, such as Turner syndrome, cause aortic aneurysms.”
D. “Aortic aneurysms are only caused by lifestyle factors, not genetic predisposition.”
B. “You are at increased risk, but managing modifiable risk factors can help reduce your chances.”
Rationale: Although genetic factors play a role, modifiable risk factors such as hypertension control, smoking cessation, and cholesterol management significantly impact the likelihood of developing an aneurysm.
A patient with Marfan syndrome is diagnosed with a 5.5 cm thoracic aortic aneurysm (TAA). Which intervention is the priority to reduce the risk of aneurysm rupture?
A. Strict blood pressure control with beta-blockers
B. Administering high-dose statins to lower cholesterol
C. Encouraging a high-protein diet to strengthen vessel walls
D. Scheduling immediate endovascular stent placement
A. Strict blood pressure control with beta-blockers
Rationale: Marfan syndrome causes weakening of the aortic wall, making it more susceptible to dilation and rupture. Beta-blockers reduce aortic wall stress by lowering heart rate and blood pressure, decreasing the risk of dissection or rupture.
A nurse is reviewing the history of a patient with a known abdominal aortic aneurysm (AAA). Which finding is most concerning and requires immediate intervention?
A. The patient reports smoking one pack of cigarettes per day.
B. The patient’s blood pressure is 170/96 mmHg.
C. The patient has a history of hyperlipidemia and takes atorvastatin.
D. The patient has a family history of aortic aneurysms.
B. The patient’s blood pressure is 170/96 mmHg.
Rationale: Uncontrolled hypertension significantly increases the risk of aneurysm expansion and rupture by exerting excessive force on the weakened aortic wall. Blood pressure must be closely managed to prevent life-threatening complications.
A patient with a newly diagnosed aortic arch aneurysm asks the nurse about possible causes. Which of the following are associated with the development of aortic aneurysms? (SATA)
A. Atherosclerosis
B. Syphilitic infection
C. Blunt chest trauma
D. Chronic venous insufficiency
E. Turner syndrome
A. Atherosclerosis
B. Syphilitic infection
C. Blunt chest trauma
E. Turner syndrome
Rationale: Atherosclerosis contributes to aneurysm formation by weakening arterial walls. Syphilitic infections can cause aortitis, leading to aneurysm development. Blunt chest trauma can damage the aorta, predisposing it to aneurysm formation. Turner syndrome is associated with congenital cardiovascular abnormalities, including aortic coarctation and aneurysms.
A 59-year-old male with a history of smoking, hyperlipidemia, and hypertension undergoes screening for an aortic aneurysm. Which screening method is most appropriate based on his risk factors?
A. Chest X-ray
B. Coronary angiography
C. Abdominal ultrasound
D. Stress echocardiogram
C. Abdominal ultrasound
Rationale: Abdominal ultrasound is the recommended screening test for men ages 65-75 who have ever smoked or have risk factors for abdominal aortic aneurysms. It is noninvasive, cost-effective, and highly sensitive for detecting aneurysms.
A nurse is caring for a postoperative patient who underwent endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA). Which assessment finding requires immediate notification of the provider?
A. Urine output of 20 mL/hr for the past 3 hours
B. Bilateral pedal pulses +2 and equal
C. Blood pressure of 132/78 mmHg
D. Mild groin discomfort near the surgical site
A. Urine output of 20 mL/hr for the past 3 hours
Rationale: A urine output of less than 30 mL/hr suggests possible renal hypoperfusion or acute kidney injury (AKI), which can occur due to impaired blood flow to the renal arteries after aneurysm repair. This finding requires immediate intervention to assess for complications such as renal artery occlusion.
A nurse is assessing a patient with a known fusiform abdominal aortic aneurysm (AAA). Based on the classification of aneurysms, which statement best describes this type of aneurysm?
A. “It is a pouch-like bulge that is connected to one side of the arterial wall.”
B. “It occurs due to a complete rupture of the arterial wall layers, with blood leaking into surrounding structures.”
C. “It involves the entire circumference of the artery and is uniform in shape.”
D. “It occurs only at the site of a previous vascular procedure or trauma.”
C. “It involves the entire circumference of the artery and is uniform in shape.”
Rationale: A fusiform aneurysm is a true aneurysm that affects the entire circumference of the artery, creating a uniform, dilated appearance. It is different from a saccular aneurysm, which is pouch-like and affects only one side of the artery.
A nurse is caring for a patient with a false aneurysm (pseudoaneurysm). Which of the following conditions could have contributed to the development of this complication? (SATA)
A. Trauma to the artery
B. History of intraaortic balloon pump placement
C. Chronic hypertension
D. Arterial leakage after catheter removal
E. Atherosclerosis
A. Trauma to the artery
B. History of intraaortic balloon pump placement
D. Arterial leakage after catheter removal
Rationale: False aneurysms (pseudoaneurysms) occur due to a disruption of all arterial wall layers, leading to bleeding that is contained by surrounding tissues. Trauma, arterial interventions (such as intraaortic balloon pump placement), and catheter removal can cause arterial wall damage and leakage, leading to pseudoaneurysm formation.
A nurse is explaining the difference between true and false aneurysms to a group of nursing students. Which statement by a student indicates a correct understanding of false aneurysms?
A. “A false aneurysm maintains at least one intact arterial wall layer.”
B. “False aneurysms are a result of atherosclerotic plaque weakening the arterial wall.”
C. “False aneurysms occur due to a complete arterial wall rupture, but bleeding is contained by surrounding tissue.”
D. “A false aneurysm is always a congenital condition.”
C. “False aneurysms occur due to a complete arterial wall rupture, but bleeding is contained by surrounding tissue.”
Rationale: A false aneurysm (pseudoaneurysm) results from a complete disruption of all layers of the arterial wall, leading to blood leakage that is confined by surrounding tissues. Unlike true aneurysms, false aneurysms do not have an intact vessel layer forming their structure.
A patient who recently underwent femoral artery catheterization is now experiencing a pulsatile mass near the insertion site, along with localized bruising and pain. Which complication does the nurse suspect?
A. Fusiform aneurysm
B. Saccular aneurysm
C. False aneurysm
D. Aortic dissection
C. False aneurysm
Rationale: A false aneurysm (pseudoaneurysm) can occur after femoral artery catheterization due to arterial wall disruption at the catheter insertion site. This results in contained bleeding, often presenting as a pulsatile mass with localized pain and bruising.
A nurse is caring for a patient diagnosed with a saccular thoracic aortic aneurysm. Which characteristics are associated with this type of aneurysm? (SATA)
A. It is a pouch-like bulge on one side of the artery.
B. It affects the entire circumference of the artery.
C. It has a narrow neck that connects it to the arterial wall.
D. It results from a complete arterial wall rupture.
E. It is classified as a true aneurysm.
A. It is a pouch-like bulge on one side of the artery.
C. It has a narrow neck that connects it to the arterial wall.
E. It is classified as a true aneurysm.
Rationale: A saccular aneurysm is a true aneurysm characterized by a pouch-like bulge on one side of the arterial wall, with a narrow neck connecting the bulge to the artery. Unlike fusiform aneurysms, which affect the entire circumference of the artery, saccular aneurysms are asymmetrical.
A 72-year-old male with a history of hypertension and coronary artery disease presents to the emergency department with deep, diffuse chest pain that radiates to the interscapular area. He also reports hoarseness and difficulty swallowing. The nurse suspects a thoracic aortic aneurysm (TAA).
Which additional assessment finding would support this suspicion?
A. Bilateral inspiratory wheezes
B. Jugular venous distention and facial edema
C. Hyperactive bowel sounds in all four quadrants
D. Pain relief when lying flat
B. Jugular venous distention and facial edema
Rationale: A thoracic aortic aneurysm (TAA) can compress the superior vena cava, leading to decreased venous return, which manifests as jugular venous distention (JVD) and facial or arm edema.
A nurse is assessing a patient with a suspected ascending aortic aneurysm. Which clinical manifestations would support this diagnosis? (SATA)
A. Angina
B. Transient ischemic attacks (TIAs)
C. Blue toe syndrome
D. Hoarseness
E. Difficulty swallowing
A. Angina
B. Transient ischemic attacks (TIAs)
D. Hoarseness
E. Difficulty swallowing
Rationale: Ascending aortic aneurysms can cause:
* Angina due to decreased coronary artery blood flow.
* TIAs due to impaired blood flow to the carotid arteries.
* Hoarseness and difficulty swallowing due to pressure on the laryngeal nerve.
A 67-year-old male is diagnosed with an abdominal aortic aneurysm (AAA) during a routine physical exam. Which finding is most characteristic of an AAA?
A. Bilateral lower extremity edema
B. Weak carotid pulses with bradycardia
C. Crackles and wheezing on lung auscultation
D. Pulsatile mass in the periumbilical area
D. Pulsatile mass in the periumbilical area
Rationale: A pulsatile mass slightly to the left of the midline in the periumbilical area is a hallmark of AAA. It may be asymptomatic and discovered incidentally during physical assessment or imaging.
A patient with a large AAA reports back pain and epigastric discomfort. The nurse is concerned that the aneurysm may be compressing nearby structures.
Which additional symptom would further support this concern?
A. Altered bowel elimination
B. Chest tightness that improves with deep breathing
C. Intermittent fever and chills
D. Productive cough with purulent sputum
A. Altered bowel elimination
Rationale: Large AAAs can compress nearby anatomic structures and nerves, leading to symptoms such as back pain, epigastric discomfort, and altered bowel elimination.
A patient with an AAA is being monitored for potential complications. The nurse understands that an AAA can spontaneously embolize plaque, causing which manifestations? (SATA)
A. Patchy mottling of feet and toes
B. Palpable pedal pulses
C. Severe chest pain with radiation to the left arm
D. Cold, cyanotic toes despite good pulses
E. Absent bowel sounds
A. Patchy mottling of feet and toes
B. Palpable pedal pulses
D. Cold, cyanotic toes despite good pulses
Rationale: Blue toe syndrome occurs when an AAA emboli dislodge plaque, leading to patchy mottling (A) and cold, cyanotic toes (D) despite palpable pedal pulses (B).
A nurse is assessing an obese patient with a suspected AAA. The nurse knows that physical findings of an AAA may be difficult to detect in this patient.
Which assessment method would be most effective in confirming an AAA?
A. Palpation of femoral pulses
B. Abdominal percussion
C. Computed tomography (CT) scan
D. Assessing for dependent edema
C. Computed tomography (CT) scan
Rationale: Physical examination may not detect an AAA in obese patients. A CT scan is the most reliable diagnostic tool to confirm its presence.
A patient with an AAA reports severe back pain and sudden onset of blue toe syndrome. What is the most concerning potential complication?
A. Acute arterial occlusion
B. Aneurysm rupture
C. Hypertensive crisis
D. Deep vein thrombosis
B. Aneurysm rupture
Rationale: Severe back pain and blue toe syndrome in an AAA patient may indicate impending rupture, a life-threatening emergency.
A 55-year-old male with a history of smoking and hypertension reports coughing, shortness of breath, and difficulty swallowing. A thoracic aortic aneurysm is suspected.
Which assessment finding would best confirm this diagnosis?
A. Diminished breath sounds in the lower lung fields
B. Widened mediastinum on chest X-ray
C. Positive sputum culture for bacteria
D. Hyperresonance on lung percussion
B. Widened mediastinum on chest X-ray
Rationale: A widened mediastinum on chest X-ray is a classic finding of a thoracic aortic aneurysm (TAA).
A nurse is educating a patient with a newly diagnosed AAA. Which patient statements indicate a need for further teaching?
A. “I should report sudden severe back pain to my doctor immediately.”
B. “Since my aneurysm is small, I don’t need to follow up with my provider regularly.”
C. “If I notice my feet turning blue, I should call my doctor.”
D. “As long as I don’t feel any symptoms, my aneurysm is not growing.”
E. “Quitting smoking can help slow the growth of my aneurysm.”
B. “Since my aneurysm is small, I don’t need to follow up with my provider regularly.”
D. “As long as I don’t feel any symptoms, my aneurysm is not growing.”
Rationale:
* (B) Incorrect—Even small AAAs require regular monitoring to assess for growth and risk of rupture.
* (D) Incorrect—Many AAAs are asymptomatic, but they can still expand and rupture without warning.
A 68-year-old male with a history of hypertension and tobacco use presents to the emergency department with sudden severe back pain. On assessment, the nurse notes bruising on the patient’s flanks (Grey Turner sign). Which complication does the nurse suspect?
A. Acute pancreatitis
B. Ruptured abdominal aortic aneurysm (AAA)
C. Upper gastrointestinal bleed
D. Spontaneous pneumothorax
B. Ruptured abdominal aortic aneurysm (AAA)
Rationale: Grey Turner sign (flank bruising) with severe back pain is highly suggestive of retroperitoneal hemorrhage due to a ruptured AAA. Surrounding structures may temporarily contain the bleeding, delaying complete exsanguination.
A patient with a suspected ruptured thoracic aortic aneurysm (TAA) is admitted to the ICU. The nurse knows that a rupture into the thoracic or abdominal cavity can cause hypovolemic shock.
Which findings would confirm this suspicion?
A. Tachycardia
B. Hypotension
C. Warm, flushed skin
D. Decreased urine output
E. Altered level of consciousness
A. Tachycardia
B. Hypotension
D. Decreased urine output
E. Altered level of consciousness
Rationale: Massive hemorrhage from an aneurysm rupture leads to hypovolemic shock, which presents with:
* Tachycardia (A) as a compensatory mechanism to maintain perfusion.
* Hypotension (B) due to blood loss.
* Decreased urine output (D) from poor renal perfusion.
* Altered level of consciousness (E) from decreased cerebral perfusion.
A patient with a known AAA suddenly becomes pale, diaphoretic, and confused, with a blood pressure of 78/42 mmHg and heart rate of 128 bpm. What is the priority nursing intervention?
A. Obtain a 12-lead ECG
B. Initiate fluid resuscitation with IV crystalloids
C. Place the patient in the Trendelenburg position
D. Prepare the patient for an emergent CT scan
B. Initiate fluid resuscitation with IV crystalloids
Rationale: The patient is exhibiting signs of hypovolemic shock from a suspected aneurysm rupture. Immediate fluid resuscitation with IV crystalloids is the priority to support circulation and maintain perfusion while preparing for surgical intervention.
A patient with a ruptured AAA is undergoing emergency surgery. The nurse anticipates which postoperative complication due to prolonged hypotension and hemorrhage?
A. Acute kidney injury
B. Hypervolemia
C. Deep vein thrombosis
D. Respiratory alkalosis
A. Acute kidney injury
Rationale: Prolonged hypotension and hemorrhage lead to decreased renal perfusion, increasing the risk for acute kidney injury (AKI) due to ischemia of the renal tubules.
A nurse is caring for a patient with a known AAA who is at high risk for rupture. The nurse should monitor for which early warning signs of impending rupture? (SATA)
A. New onset severe back pain
B. Sudden, severe headache
C. Pulsatile abdominal mass
D. Drop in blood pressure
E. Flank ecchymosis
A. New onset severe back pain
C. Pulsatile abdominal mass
D. Drop in blood pressure
E. Flank ecchymosis
Rationale: Warning signs of an impending aneurysm rupture include:
* New onset severe back pain (A) from expansion or impending rupture.
* Pulsatile abdominal mass (C) suggests an enlarging AAA.
* Drop in blood pressure (D) may indicate hemorrhage.
* Flank ecchymosis (E) (Grey Turner sign) suggests retroperitoneal bleeding.
A 74-year-old patient with a history of smoking and a 7.2 cm AAA asks the nurse, “What is my risk of rupture?” What is the best response by the nurse?
A. “Since your aneurysm is over 5 cm, the risk of rupture is high.”
B. “Smoking doesn’t affect your risk of rupture.”
C. “Your aneurysm will likely remain stable if you monitor your blood pressure.”
D. “Aneurysm rupture is unpredictable and does not correlate with size.”
A. “Since your aneurysm is over 5 cm, the risk of rupture is high.”
Rationale: Aneurysms larger than 5 cm have a significantly increased risk of rupture, and the risk rises further as size increases. Tobacco use is the most important modifiable risk factor, increasing rupture likelihood.
A 70-year-old male with a history of hypertension and smoking presents with chest pain radiating to the back. The healthcare provider suspects a thoracic aortic aneurysm (TAA).
Which diagnostic test should the nurse anticipate to confirm the presence, location, and severity of the aneurysm?
A. Chest x-ray
B. 12-lead ECG
C. CT scan with contrast
D. Echocardiogram
C. CT scan with contrast
Rationale: A CT scan with contrast is the gold standard for diagnosing aortic aneurysms. It provides detailed imaging of the aneurysm’s size, location, and involvement of surrounding structures, allowing for surgical planning if needed.
A nurse is explaining the diagnostic process for an abdominal aortic aneurysm (AAA) to a patient. Which diagnostic tests are commonly used to detect or monitor an AAA? (SATA)
A. Abdominal ultrasound
B. CT scan
C. MRI
D. 12-lead ECG
E. Pulmonary function test
A. Abdominal ultrasound
B. CT scan
C. MRI
Rationale:
* Abdominal ultrasound (A) is the initial screening tool for AAA and is used for routine monitoring.
* CT scan (B) provides detailed size and anatomical information for surgical planning.
* MRI (C) can be used if contrast dye is contraindicated (e.g., renal impairment).
* A 12-lead ECG (D) is done to rule out MI but does not diagnose aneurysms.
* Pulmonary function tests (E) are unrelated to aneurysm diagnosis.
A patient with suspected thoracic aortic aneurysm (TAA) undergoes an ECG, which shows normal sinus rhythm with no ischemic changes. The patient asks why this test was done. What is the best explanation by the nurse?
A. “An ECG can confirm if you have an aneurysm.”
B. “Aneurysms cause changes in heart rhythm, which we can see on the ECG.”
C. “We needed to rule out a heart attack, since aneurysm pain can mimic angina.”
D. “The ECG helps us measure the size of your aneurysm.”
C. “We needed to rule out a heart attack, since aneurysm pain can mimic angina.”
Rationale: Thoracic aortic aneurysm (TAA) can present with chest pain similar to angina or an MI. An ECG is done to rule out cardiac ischemia before proceeding with aneurysm-specific imaging, such as a CT scan or MRI.
A 55-year-old male with a strong family history of AAA asks about screening recommendations. Which diagnostic test should the nurse recommend based on current guidelines?
A. Abdominal x-ray
B. Chest x-ray
C. Exercise stress test
D. Abdominal ultrasound
D. Abdominal ultrasound
Rationale: Abdominal ultrasound is the preferred screening tool for AAA, especially in men aged 65-75 who have ever smoked or have a family history. It is non-invasive, cost-effective, and reliable for detecting aneurysm size.
A 67-year-old male with a 4.8 cm abdominal aortic aneurysm (AAA) is being managed conservatively. Which intervention is the priority in preventing aneurysm expansion?
A. Encouraging tobacco cessation
B. Scheduling immediate surgical repair
C. Restricting all physical activity
D. Monitoring for signs of aneurysm rupture daily
A. Encouraging tobacco cessation
Rationale: Tobacco use is the most important modifiable risk factor for aneurysm growth and rupture. Stopping smoking slows the progression of the aneurysm. Conservative management is recommended for small aneurysms (<5.4 cm) unless symptoms develop or rapid expansion occurs.
The nurse is providing education to a patient with a small, asymptomatic AAA (3.9 cm). Which instructions should the nurse include? (SATA)
A. Monitor BP regularly and take antihypertensives as prescribed.
B. Follow up with an ultrasound every 6 months.
C. Increase physical activity gradually.
D. Avoid statin therapy unless the aneurysm enlarges.
E. Report any new abdominal or back pain immediately.
A. Monitor BP regularly and take antihypertensives as prescribed.
C. Increase physical activity gradually.
E. Report any new abdominal or back pain immediately.
Rationale:
* A. BP control is essential to prevent aneurysm expansion.
* C. Gradually increasing physical activity is beneficial for overall cardiovascular health.
* E. New or worsening pain can indicate aneurysm expansion or impending rupture.
* B. Aneurysms <4.0 cm should be monitored every 3 years, not every 6 months.
* D. Statins are recommended to manage hyperlipidemia and reduce cardiovascular risk.
A patient with an asymptomatic 5.6 cm AAA is scheduled for surgical repair. What factor would prompt earlier intervention?
A. Stable aneurysm size over 1 year
B. Well-controlled hypertension
C. Diagnosis of Marfan syndrome
D. Absence of symptoms
C. Diagnosis of Marfan syndrome
Rationale: Patients with genetic disorders like Marfan or Ehlers-Danlos syndrome have a higher risk of rupture even at smaller aneurysm sizes, so they require earlier surgical intervention.
A 72-year-old male with a history of hypertension and hyperlipidemia has an AAA measuring 4.3 cm. Which medication should the nurse anticipate being prescribed to slow aneurysm growth?
A. ACE inhibitor
B. Beta-blocker
C. Corticosteroid
D. Anticoagulant
A. ACE inhibitor
Rationale: ACE inhibitors reduce hypertension and may help slow aneurysm expansion. They also have protective effects on the vascular endothelium.
A nurse is reviewing a patient’s chart before AAA repair surgery. Which preoperative assessments should be prioritized? (SATA)
A. Assessment of carotid artery disease
B. History of coronary artery disease (CAD)
C. Presence of diabetes mellitus
D. Oxygen saturation at rest
E. Family history of thyroid disease
A. Assessment of carotid artery disease
B. History of coronary artery disease (CAD)
C. Presence of diabetes mellitus
Rationale:
* A. Carotid artery disease should be assessed because severe stenosis may require intervention before aneurysm surgery.
* B. CAD increases surgical risk and may require preoperative optimization.
* C. Diabetes management is critical to reduce complications during and after surgery.
* D. Oxygen saturation is important but not a primary surgical consideration.
* E. Thyroid disease is unrelated to aneurysm management.
A nurse is discussing ultrasound surveillance recommendations with a patient who has an AAA measuring 4.7 cm. What is the appropriate monitoring interval?
A. Every 3 years
B. Every 12 months
C. Every 6 to 12 months
D. Every 3 months
C. Every 6 to 12 months
Rationale: For aneurysms between 4.0 and 5.4 cm, ultrasound or CT should be done every 6 to 12 months to monitor for growth. Aneurysms <4.0 cm are monitored every 3 years.
A patient with a small AAA (3.8 cm) asks how to reduce the risk of aneurysm progression. Which response by the nurse is most appropriate?
A. “There is nothing you can do to slow the aneurysm’s growth.”
B. “Maintaining good blood pressure and cholesterol control is essential.”
C. “You should avoid all physical activity to prevent stress on the aorta.”
D. “Once an aneurysm forms, it always requires surgery.”
B. “Maintaining good blood pressure and cholesterol control is essential.”
Rationale: Hypertension and hyperlipidemia accelerate aneurysm growth. Managing these risk factors can slow progression and reduce the likelihood of rupture.
A 68-year-old male with an asymptomatic 6.0 cm abdominal aortic aneurysm (AAA) is scheduled for an open aneurysm repair (OAR). What preoperative intervention is most important for reducing postoperative complications?
A. Administering anticoagulants to prevent thrombus formation
B. Ensuring the patient is well hydrated with stable electrolytes
C. Encouraging ambulation the morning of surgery to prevent DVT
D. Keeping the patient NPO for 24 hours before surgery
B. Ensuring the patient is well hydrated with stable electrolytes
Rationale: Adequate hydration, normal electrolyte levels, and a stable hematocrit reduce the risk of complications during and after surgery. Proper fluid balance prevents acute kidney injury (AKI), which is a major risk when the aorta is clamped for an extended period.
A nurse is preparing a patient for elective open aneurysm repair (OAR). Which preoperative assessments are essential? (SATA)
A. Baseline renal function tests
B. Coagulation profile
C. Neurological assessment
D. Serum albumin levels
E. Pulmonary function tests
A. Baseline renal function tests
B. Coagulation profile
C. Neurological assessment
E. Pulmonary function tests
Rationale:
* A. Renal function tests (BUN, creatinine) are crucial because prolonged aortic clamping can lead to acute kidney injury.
* B. A coagulation profile is necessary to prevent excessive bleeding during surgery.
* C. Neurological assessment is important since aneurysms affecting the aortic arch can impact cerebral perfusion.
* E. Pulmonary function tests help assess risk for postoperative respiratory complications, especially in patients with preexisting lung disease.
* D. Serum albumin is not a priority unless malnutrition is suspected.
A nurse is caring for a patient recovering from open aneurysm repair (OAR) of an abdominal aortic aneurysm (AAA) above the renal arteries. What is the priority assessment in the immediate postoperative period?
A. Monitoring urine output closely
B. Checking the surgical incision for signs of infection
C. Encouraging deep breathing and coughing exercises
D. Assessing bowel sounds every 2 hours
A. Monitoring urine output closely
Rationale: Clamping the aorta above the renal arteries during surgery increases the risk of acute kidney injury (AKI). The nurse must monitor urine output closely, as decreased output (<30 mL/hr) may indicate impaired renal perfusion.
A nurse is providing discharge instructions for a patient after open abdominal aneurysm repair (OAR). Which postoperative complications should the patient report immediately? (SATA)
A. Sudden severe abdominal or back pain
B. Redness and warmth at the incision site
C. Decreased urine output
D. Intermittent nausea and bloating
E. Numbness or tingling in the legs
A. Sudden severe abdominal or back pain
C. Decreased urine output
E. Numbness or tingling in the legs
Rationale:
* A. Sudden severe abdominal or back pain may indicate graft rupture or bleeding.
* C. Decreased urine output may suggest acute kidney injury from impaired renal perfusion.
* E. Numbness or tingling in the legs could indicate impaired blood flow or nerve damage.
* B. Redness and warmth at the incision site may indicate infection but is not an emergency.
* D. Mild nausea and bloating can occur postoperatively but is not a priority concern.
A patient is undergoing open aneurysm repair (OAR) for a large thoracic aortic aneurysm. During surgery, the surgeon must cross-clamp the aorta for an extended period. The nurse should anticipate which postoperative complication?
A. Paralytic ileus
B. Spinal cord ischemia
C. Deep vein thrombosis
D. Atelectasis
B. Spinal cord ischemia
Rationale: Cross-clamping the aorta for an extended period can reduce blood flow to the spinal cord, leading to ischemia and possible paralysis. The risk is higher in thoracic aneurysm repairs.
A nurse is reviewing a patient’s chart after open aneurysm repair (OAR). The patient had an iliac artery aneurysm and received a bifurcated graft. What is the primary purpose of this graft?
A. To reduce the risk of clot formation
B. To allow the artery to heal naturally over time
C. To prevent the need for postoperative anticoagulation therapy
D. To replace the entire diseased arterial segment
D. To replace the entire diseased arterial segment
Rationale: A bifurcated graft is used when aneurysms involve the iliac arteries, replacing the diseased segment entirely. This ensures restored circulation to both lower extremities.
A nurse is caring for a 76-year-old male who just underwent open abdominal aneurysm repair (OAR). His urine output has decreased to 20 mL/hr over the last 3 hours, and his BUN and creatinine levels are rising. What is the nurse’s best initial action?
A. Increase IV fluid rate as ordered
B. Administer diuretics as prescribed
C. Position the patient in Trendelenburg
D. Apply warm compresses to the lower back
A. Increase IV fluid rate as ordered
Rationale: Decreased urine output and rising BUN/creatinine levels indicate impaired renal perfusion. Increasing IV fluids improves renal blood flow and may prevent acute kidney injury.
A 65-year-old male is scheduled for endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm. Which criteria makes this patient eligible for EVAR?
A. The patient has aortic occlusion in the iliac arteries
B. The patient has extensive calcification in the femoral arteries
C. The patient’s iliac vessels are large enough to allow graft insertion
D. The patient has a history of heart failure
C. The patient’s iliac vessels are large enough to allow graft insertion
Rationale: Endovascular graft procedure (EVAR) requires that the iliac vessels are of adequate size and shape to allow safe graft insertion. Calcification, occlusion, or other significant vessel abnormalities would preclude EVAR.
Which of the following is true regarding endovascular aneurysm repair (EVAR) compared to open aneurysm repair (OAR)?
A. EVAR involves a longer hospital stay than OAR
B. EVAR has a higher risk of complications like paraplegia and death
C. EVAR requires general anesthesia, whereas OAR may be performed with local anesthesia
D. EVAR is less invasive and associated with fewer complications than OAR
D. EVAR is less invasive and associated with fewer complications than OAR
Rationale: EVAR is a minimally invasive procedure compared to OAR, which involves a large abdominal incision. EVAR has fewer complications, such as paraplegia, and typically results in a shorter hospital stay.
After a patient undergoes endovascular aneurysm repair (EVAR), the nurse should monitor for which potential complications? (SATA)
A. Endograft migration
B. Rupture of the aneurysm
C. Paralysis or paraplegia
D. Graft infection
E. Leaks at the graft site
A. Endograft migration
B. Rupture of the aneurysm
D. Graft infection
E. Leaks at the graft site
Rationale:
* A. Endograft migration may occur if the graft does not securely adhere to the vessel wall.
* B. Rupture of the aneurysm is still a risk if the graft is not placed properly or develops leaks.
* D. Graft infection is a potential risk as the graft is a foreign object inserted into the body.
* E. Leaks at the graft site can occur, which may compromise the repair and require additional intervention.
A nurse is caring for a patient who recently had endovascular aneurysm repair (EVAR). The nurse notes a pulsatile mass near the graft site. What is the priority action?
A. Encourage the patient to ambulate to improve circulation
B. Notify the healthcare provider for potential graft complication
C. Apply a warm compress to the site to reduce swelling
D. Administer pain medication as prescribed for discomfort
B. Notify the healthcare provider for potential graft complication
Rationale: A pulsatile mass near the graft site may indicate a graft leak or other complications that require immediate evaluation by the healthcare provider.
What is the role of angiography following endovascular aneurysm repair (EVAR)?
A. To confirm the patency and position of the graft
B. To evaluate the need for anticoagulation therapy
C. To assess the patient’s kidney function postoperatively
D. To check for atherosclerosis in the iliac arteries
A. To confirm the patency and position of the graft
Rationale: Angiography is performed after EVAR to confirm that the graft is properly positioned and functioning, ensuring there are no leaks or obstructions.
A 74-year-old female is undergoing endovascular aneurysm repair (EVAR) for a large abdominal aortic aneurysm. Which of the following is the most significant post-procedure consideration?
A. Monitoring the patient for signs of infection
B. Monitoring for signs of graft rupture or migration
C. Encouraging early ambulation to prevent thromboembolism
D. Ensuring the patient receives an adequate fluid intake to prevent dehydration
B. Monitoring for signs of graft rupture or migration
Rationale: After EVAR, the most significant concern is graft integrity, which includes monitoring for graft rupture or migration. Prompt detection is essential to prevent aneurysm rupture.
A nurse is preparing a patient for endovascular aneurysm repair (EVAR). What is the most important preoperative assessment for ensuring successful graft insertion?
A. Checking the patient’s clotting profile
B. Assessing the patient’s respiratory status due to anesthesia risks
C. Performing a baseline neurological assessment
D. Ensuring the patient’s vessels are of adequate size for graft insertion
D. Ensuring the patient’s vessels are of adequate size for graft insertion
Rationale: Successful graft insertion depends on the size and integrity of the iliac vessels. If the vessels are too small or too calcified, the patient may not be eligible for EVAR.
Which of the following is the most common complication following AAA repair?
A. Aortic dissection
B. Endoleak
C. Renal artery occlusion
D. Abdominal compartment syndrome
B. Endoleak
Rationale: Endoleak is the most common complication after AAA repair, where blood seeps back into the old aneurysm. This complication may require further intervention such as coil embolization for hemostasis.
A patient who recently underwent endovascular aneurysm repair (EVAR) for an AAA presents with signs of hypotension, tachycardia, and back pain. Upon imaging, the patient is diagnosed with a graft thrombosis. Which of the following interventions would be most appropriate?
A. Administering thrombolytic therapy to dissolve the clot
B. Increasing fluid resuscitation and monitoring for signs of bleeding
C. Immediate surgical exploration to remove the thrombosed graft
D. Applying pressure to the incision site to control bleeding
A. Administering thrombolytic therapy to dissolve the clot
Rationale: Graft thrombosis can be treated with thrombolytic therapy to dissolve the clot, allowing for restoration of blood flow through the graft. Immediate surgery may be required if thrombolysis is unsuccessful.
Which of the following is a potentially lethal complication associated with emergency AAA repair that could lead to multisystem organ failure?
A. Aortic dissection
B. Endoleak
C. Abdominal compartment syndrome
D. Renal artery occlusion
C. Abdominal compartment syndrome
Rationale: Abdominal compartment syndrome is a life-threatening complication of AAA repair that leads to multisystem organ failure due to intraabdominal hypertension (IAH), reducing blood flow to vital organs.
A nurse is caring for a patient who has undergone EVAR for an AAA and is monitoring for complications. Which of the following findings indicate the potential presence of an endoleak? (SATA)
A. Back pain and hypotension
B. Pulse deficits in the lower extremities
C. Pulsatile mass at the graft site
D. Increased serum creatinine levels
E. Bruit over the aorta
A. Back pain and hypotension
C. Pulsatile mass at the graft site
E. Bruit over the aorta
Rationale:
* A. Back pain and hypotension may be signs of bleeding or an endoleak.
* C. Pulsatile mass at the graft site could indicate an endoleak or other complications, such as a graft issue.
* E. Bruit over the aorta suggests turbulent blood flow, which can be caused by an endoleak.
A patient is being monitored postoperatively after AAA repair. Which of the following complications should the nurse be most concerned about in the first 24 hours postoperatively?
A. Endoleak
B. Graft thrombosis
C. Abdominal compartment syndrome
D. Renal artery occlusion
C. Abdominal compartment syndrome
Rationale: Abdominal compartment syndrome can develop rapidly after AAA repair and lead to multisystem organ failure. Monitoring for signs of intraabdominal hypertension (IAH) is critical in the first 24 hours.
A 70-year-old male patient who underwent EVAR for an AAA 3 months ago reports worsening lower back pain and tenderness at the incision site. The nurse notes a change in the patient’s vital signs, with a drop in blood pressure and increased heart rate.
Which of the following is the priority action?
A. Notify the healthcare provider about possible graft rupture
B. Administer analgesics and encourage deep breathing exercises
C. Check for signs of incisional infection
D. Encourage the patient to ambulate to relieve pain
A. Notify the healthcare provider about possible graft rupture
Rationale: Back pain and hypotension following AAA repair could indicate graft rupture, which requires immediate medical intervention to prevent hemorrhagic shock and other life-threatening complications.
A nurse is caring for a patient who developed intraabdominal hypertension (IAH) following emergency AAA repair. What is the most appropriate intervention to manage IAH?
A. Administering antihypertensive medication
B. Initiating percutaneous drainage and possibly thrombolytics
C. Administering high doses of opioid analgesics
D. Encouraging patient ambulation
B. Initiating percutaneous drainage and possibly thrombolytic
Rationale: The treatment for IAH may involve surgical decompression, percutaneous drainage, and thrombolytic therapy to reduce intraabdominal pressure and prevent multisystem organ failure.
Which of the following is a long-term follow-up requirement for a patient who has undergone EVAR for an AAA?
A. Periodic echocardiograms to assess heart function
B. Routine urine culture testing for infection
C. Regular blood glucose monitoring to assess for diabetes
D. Periodic imaging to monitor for endoleak or aneurysm expansion
D. Periodic imaging to monitor for endoleak or aneurysm expansion
Rationale: Periodic imaging (such as ultrasound or CT) is required to monitor for complications like endoleak or aneurysm growth following EVAR. This ensures early detection and timely intervention to prevent rupture.
When assessing a patient with a suspected aortic aneurysm rupture, which of the following findings would be most concerning and should prompt immediate intervention?
A. Diaphoresis and abdominal pain
B. Weak peripheral pulses and dizziness
C. Tachycardia, hypotension, and changes in level of consciousness
D. Pale skin and decreased urine output
C. Tachycardia, hypotension, and changes in level of consciousness
Rationale: Tachycardia, hypotension, and changes in level of consciousness are signs of hemorrhagic shock associated with aortic aneurysm rupture, requiring immediate intervention to prevent death.
A patient who is scheduled for aortic aneurysm surgery has a history of hypertension, smoking, and hyperlipidemia. Which of the following actions is most important for the nurse to address during the preoperative period?
A. Marking the pedal pulse sites with a marker
B. Monitoring the patient’s oxygen saturation
C. Administering an antihypertensive medication
D. Encouraging cessation of smoking
D. Encouraging cessation of smoking
Rationale: Smoking cessation is a priority as it is a significant risk factor for aortic aneurysm development and rupture. It also contributes to poor graft patency and worsens cardiovascular disease.
A nurse is conducting a preoperative assessment on a patient who will undergo surgical repair of an aortic aneurysm. Which of the following assessment findings would be most concerning to monitor closely during the perioperative period? (SATA)
A. Diaphoresis and weakness
B. Pale skin and absent pedal pulses
C. Changes in level of consciousness and groin pain
D. A pulsating abdominal mass and hypotension
E. Decreased urine output and tachycardia
B. Pale skin and absent pedal pulses
C. Changes in level of consciousness and groin pain
D. A pulsating abdominal mass and hypotension
E. Decreased urine output and tachycardia
Rationale:
* B. Pale skin and absent pedal pulses could indicate poor circulation and compromise to peripheral perfusion.
* C. Changes in level of consciousness and groin pain are concerning for a ruptured aneurysm.
* D. A pulsating abdominal mass and hypotension are classic signs of an impending rupture.
* E. Decreased urine output and tachycardia could suggest shock or renal compromise, both of which require immediate intervention.
A nurse is preparing a patient for surgical repair of an aortic aneurysm. What should the nurse specifically monitor to ensure adequate tissue perfusion postoperatively?
A. The patient’s cardiac rhythm and blood pressure
B. The integrity of the incision site
C. The patient’s respiratory rate and oxygen saturation
D. The patient’s peripheral pulses and renal function
D. The patient’s peripheral pulses and renal function
Rationale: Peripheral pulses and renal function are critical indicators of adequate tissue perfusion after aortic aneurysm surgery. Monitoring these helps detect complications such as renal failure or impaired blood flow to extremities.
Which of the following health promotion interventions should the nurse recommend to a patient with an aortic aneurysm to reduce cardiovascular disease (CVD) risk factors?
A. Encouraging smoking cessation
B. Increasing salt intake to maintain blood pressure
C. Promoting bed rest until surgery
D. Limiting physical activity to prevent aneurysm rupture
A. Encouraging smoking cessation
Rationale: Smoking cessation is a critical intervention for reducing CVD risk and preventing aortic aneurysm rupture. It improves vascular health, enhances graft patency, and reduces the likelihood of complications.
A patient with a history of atherosclerosis and a recently diagnosed abdominal aortic aneurysm (AAA) is being prepared for surgery. Which of the following nursing interventions should be prioritized during the preoperative period?
A. Encouraging the patient to quit smoking immediately
B. Marking the pedal pulses to assess for future changes
C. Administering a statin to lower cholesterol levels
D. Teaching the patient about potential complications after surgery
A. Encouraging the patient to quit smoking immediately
Rationale: Smoking cessation has the most immediate and significant impact on preventing aneurysm rupture and improving surgical outcomes. Encouraging this behavior change should be a top priority.
Which of the following is an important preoperative nursing action for a patient scheduled for aortic aneurysm repair surgery?
A. Administering prophylactic antibiotics to prevent infection
B. Performing a complete neurological assessment
C. Starting a low-dose heparin infusion to prevent thrombosis
D. Ensuring the patient is well-hydrated and has normal electrolytes
D. Ensuring the patient is well-hydrated and has normal electrolytes
Rationale: Adequate hydration and normal electrolyte levels are essential for ensuring the patient’s stability before aortic aneurysm surgery, especially since the surgery involves major vascular repair and the risk of fluid imbalances is high.
A patient who has undergone aortic aneurysm surgery is being transferred to the ICU. Which of the following monitoring devices should the nurse expect to be in place upon the patient’s arrival?
A. Arterial line and central venous pressure (CVP) catheter
B. Chest tube and lumbar catheter
C. Peripheral IV lines and nasogastric (NG) tube
D. All of the above
D. All of the above
Rationale: After aortic aneurysm surgery, the patient will have various monitoring devices in place, including an arterial line, CVP catheter, chest tube (if thorax is opened), lumbar catheter for cerebrospinal fluid drainage, peripheral IV lines, and an NG tube to monitor and support post-operative care.
Which of the following actions is most important for the nurse to take prior to a patient undergoing aortic aneurysm surgery?
A. Administering a β-blocker to the patient
B. Ensuring the patient is NPO after midnight
C. Providing pain medication through an epidural catheter
D. Initiating IV antibiotic therapy before surgery
B. Ensuring the patient is NPO after midnight
Rationale: NPO status after midnight helps prevent aspiration during surgery. While β-blockers and IV antibiotics are also part of the plan of care, NPO status is the most critical preoperative action for patient safety.
A nurse is caring for a postoperative patient who has undergone aortic aneurysm surgery. Which of the following are priority goals for postoperative care? (SATA)
A. Maintaining adequate respiratory function
B. Monitoring for graft patency and renal perfusion
C. Promoting early ambulation
D. Administering pain medications via IV PCA
E. Ensuring continuous ECG and pulse oximetry monitoring
A. Maintaining adequate respiratory function
B. Monitoring for graft patency and renal perfusion
D. Administering pain medications via IV PCA
E. Ensuring continuous ECG and pulse oximetry monitoring
Rationale: Postoperative care involves maintaining respiratory function, ensuring graft patency, renal perfusion, and continuous monitoring (ECG and pulse oximetry). While early ambulation is important for recovery, it is not the top priority immediately after surgery. Pain control is crucial for patient comfort and recovery.
A nurse is monitoring a patient postoperatively after aortic aneurysm surgery and observes a decrease in urinary output. Which of the following is the most likely cause of this finding?
A. Impaired renal perfusion due to graft occlusion
B. Side effect of pain medication
C. Compartment syndrome
D. Increased fluid intake after surgery
A. Impaired renal perfusion due to graft occlusion
Rationale: Impaired renal perfusion can occur due to complications such as graft occlusion or hypotension postoperatively, leading to decreased urinary output. This is a key complication to monitor for in these patients.
Which of the following postoperative complications should the nurse specifically monitor for in a patient who has undergone aortic aneurysm surgery?
A. Neurologic complications, including stroke or paraplegia
B. Urinary retention due to catheter placement
C. Hypertension due to pain medication
D. Hyperglycemia from corticosteroid therapy
A. Neurologic complications, including stroke or paraplegia
Rationale: Neurologic complications such as stroke or paraplegia are serious postoperative risks, especially in patients who have had thoracic or abdominal aortic aneurysm repair. Monitoring for these complications is critical, especially in patients with lumbar catheters to prevent cerebrospinal fluid-related issues.
A patient who has had aortic aneurysm surgery is receiving pain management via an IV patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take to ensure safe and effective pain control?
A. Monitor the patient’s pain level frequently to adjust medication doses
B. Limit fluid intake to prevent fluid overload
C. Teach the patient to limit their use of the PCA to avoid overuse
D. Assess the patient’s respiratory status for signs of opioid overdose
D. Assess the patient’s respiratory status for signs of opioid overdose
Rationale: Since the patient is receiving opioids via PCA, it is critical to monitor for signs of opioid overdose, such as respiratory depression. Regular assessment of pain is also important, but the primary focus should be on preventing respiratory complications.
After aortic aneurysm surgery, which of the following interventions is most important to prevent the complication of cardiac ischemia?
A. Administering a β-blocker to reduce heart rate and myocardial oxygen demand
B. Ensuring that the patient is well-hydrated to prevent hypovolemia
C. Monitoring the patient’s coagulation status to prevent bleeding
D. Encouraging the patient to rest and limit physical activity for the first few weeks
A. Administering a β-blocker to reduce heart rate and myocardial oxygen demand
Rationale: β-blockers are commonly prescribed to reduce myocardial oxygen demand and heart rate, which can help prevent cardiac ischemia following aortic aneurysm surgery, especially in patients with pre-existing cardiovascular disease.
A patient who underwent aortic aneurysm surgery begins to show signs of infection at the surgical site, including increased redness, warmth, and purulent drainage. What is the priority action the nurse should take?
A. Obtain a wound culture and send it to the lab for testing
B. Administer broad-spectrum antibiotics as ordered
C. Notify the surgeon immediately for further evaluation
D. Perform a sterile dressing change and apply an antimicrobial agent
C. Notify the surgeon immediately for further evaluation
Rationale: Infection at the surgical site is a serious complication that can impair healing and lead to systemic infection. Notifying the surgeon is the priority action to ensure appropriate treatment and potential surgical intervention.
A nurse is monitoring a postoperative patient who has undergone aortic aneurysm surgery. Which of the following assessments is most important to ensure graft patency?
A. Monitoring the patient’s blood pressure to ensure it is within normal limits
B. Checking for signs of infection at the surgical site
C. Assessing the patient’s temperature every four hours
D. Measuring urine output hourly to assess kidney function
A. Monitoring the patient’s blood pressure to ensure it is within normal limits
Rationale: Blood pressure control is critical to maintaining graft patency. Prolonged low blood pressure may result in graft thrombosis, while severe hypertension may lead to stress on the graft, increasing the risk of rupture or leakage at the anastomoses.
A patient who recently underwent aortic aneurysm surgery presents with hypotension. The nurse recognizes that this could indicate a risk for graft thrombosis. What intervention should the nurse prioritize to address this issue?
A. Increase IV fluid administration as ordered
B. Administer IV diuretics to control fluid overload
C. Decrease the patient’s blood pressure to prevent stress on the graft
D. Administer antihypertensive agents to control blood pressure
A. Increase IV fluid administration as ordered
Rationale: Hypotension can impair graft perfusion and lead to graft thrombosis. Increasing IV fluid administration will help maintain adequate blood flow and support graft patency by restoring blood pressure and perfusion.
Which of the following actions is the most appropriate to prevent graft rupture following aortic aneurysm surgery?
A. Avoid administering IV fluids to prevent fluid overload
B. Maintain blood pressure within normal limits and avoid severe hypertension
C. Limit the patient’s intake of sodium to prevent fluid retention
D. Administer anticoagulant therapy to reduce the risk of clot formation
B. Maintain blood pressure within normal limits and avoid severe hypertension
Rationale: Maintaining blood pressure within normal limits is crucial to prevent graft rupture. Severe hypertension may place stress on the arterial anastomoses and increase the risk of leakage or rupture at the suture lines.
A nurse is monitoring a patient who has undergone aortic aneurysm surgery for signs of graft complications. Which of the following interventions are important to ensure proper graft patency during the postoperative period? (SATA)
A. Monitor CVP or PA pressures hourly
B. Administer IV antihypertensive agents as needed to control high blood pressure
C. Keep the patient on strict bed rest to avoid graft displacement
D. Assess urine output hourly to monitor kidney perfusion
E. Provide pain management with opioids to maintain comfort
A. Monitor CVP or PA pressures hourly
B. Administer IV antihypertensive agents as needed to control high blood pressure
D. Assess urine output hourly to monitor kidney perfusion
Rationale: Monitoring CVP or PA pressures and urine output hourly, along with administering IV antihypertensive agents if necessary, are essential to assess and maintain graft patency and adequate hydration and perfusion. Pain management is important for comfort, but it is not directly related to graft patency. Bed rest is not specifically required to prevent graft displacement.
A nurse is caring for a postoperative patient who has undergone aortic aneurysm surgery. The patient is at risk for myocardial ischemia or infarction in the perioperative period. Which of the following interventions should the nurse prioritize to reduce the risk of myocardial ischemia?
A. Administer IV fluids to increase blood volume
B. Ensure the patient is kept hypothermic to reduce metabolic demands
C. Monitor the patient’s ECG continuously
D. Encourage deep breathing exercises to improve oxygenation
C. Monitor the patient’s ECG continuously
Rationale: Continuous ECG monitoring is essential to detect myocardial ischemia or dysrhythmias that may occur in the perioperative period due to decreased myocardial oxygen supply or increased oxygen demand. This allows for early intervention to prevent complications.
A patient undergoing aortic aneurysm surgery is at risk for electrolyte imbalances. The nurse should monitor which of the following electrolytes most closely to prevent dysrhythmias in the postoperative period?
A. Potassium
B. Magnesium
C. Sodium
D. Chloride
A. Potassium
Rationale: Potassium is essential for electrical conduction in the heart. Electrolyte imbalances in potassium, particularly hypokalemia, can lead to dysrhythmias, so careful monitoring and correction of potassium levels is critical in preventing complications.
A nurse is caring for a postoperative patient who is receiving antidysrhythmic medication. The nurse should closely monitor which of the following parameters to assess for potential complications related to myocardial ischemia?
A. Heart rate and rhythm
B. Urine output and fluid balance
C. Respiratory rate and oxygen saturation
D. Blood glucose levels and temperature
A. Heart rate and rhythm
Rationale: Monitoring heart rate and rhythm is essential to detect dysrhythmias, which can occur due to myocardial ischemia or the use of antidysrhythmic medications. This allows for early identification and treatment of complications related to the heart’s electrical conduction.
A postoperative patient is being managed for myocardial ischemia and dysrhythmias. Which of the following interventions should the nurse implement to support the patient’s cardiovascular status during the perioperative period? (SATA)
A. Administer O2 as ordered
B. Provide pain management as needed
C. Monitor electrolyte levels frequently
D. Perform deep breathing exercises to reduce oxygen demand
E. Administer IV antihypertensive medications if the patient becomes hypertensive
A. Administer O2 as ordered
B. Provide pain management as needed
C. Monitor electrolyte levels frequently
E. Administer IV antihypertensive medications if the patient becomes hypertensive
Rationale: The nurse should administer oxygen to optimize myocardial oxygenation, provide pain management to reduce stress on the heart, monitor electrolyte levels to detect imbalances that could cause dysrhythmias, and administer IV antihypertensives as needed to prevent excessive hypertension that could increase myocardial oxygen demand. Deep breathing exercises may be helpful, but they are not a primary intervention for myocardial ischemia or dysrhythmias.
A patient who has undergone a vascular graft procedure is at risk for prosthetic vascular graft infection. Which of the following nursing interventions is most important to prevent infection?
A. Administer antibiotics as prescribed
B. Monitor for hypotension and notify the provider immediately
C. Encourage early ambulation to prevent clots
D. Change the surgical dressing every 24 hours
A. Administer antibiotics as prescribed
Rationale: The administration of broad-spectrum antibiotics as prescribed is critical in preventing infection following vascular graft surgery. Infection is a serious complication, and antibiotics help reduce the risk of bacterial invasion.
A nurse is caring for a postoperative patient who underwent vascular graft surgery. The patient develops a fever. What is the nurse’s most appropriate action?
A. Administer antipyretics as prescribed and monitor the fever
B. Immediately report the fever to the provider as it may indicate infection
C. Encourage oral fluids to reduce body temperature
D. Increase the patient’s physical activity to promote circulation
B. Immediately report the fever to the provider as it may indicate infection
Rationale: A fever following vascular graft surgery may indicate an infection. Prompt reporting to the provider allows for early diagnosis and treatment, as infection is a life-threatening complication.
A postoperative patient with a vascular graft develops an increased WBC count. What is the nurse’s priority action?
A. Administer antibiotics as ordered
B. Increase oral fluid intake to flush out the infection
C. Assess the incision site for signs of infection
D. Encourage deep breathing exercises to prevent pneumonia
C. Assess the incision site for signs of infection
Rationale: A high WBC count is an early sign of infection, and assessing the incision site for signs of infection (e.g., redness, swelling, drainage) is crucial for identifying a potential problem and providing appropriate care.
A patient has a vascular graft and is at risk for infection. Which of the following interventions should the nurse include in the care plan to reduce the risk of infection? (SATA)
A. Perform wound care as prescribed
B. Ensure good hand-washing and strict aseptic technique
C. Remove urinary catheter as soon as possible
D. Keep the surgical incisions clean and dry
E. Encourage the patient to limit oral intake to reduce infection risk
A. Perform wound care as prescribed
B. Ensure good hand-washing and strict aseptic technique
C. Remove urinary catheter as soon as possible
D. Keep the surgical incisions clean and dry
Rationale: Wound care as prescribed, aseptic technique, early catheter removal, and keeping the surgical incisions clean and dry all contribute to minimizing the risk of infection. Limiting oral intake does not directly affect infection prevention.
A nurse is caring for a postoperative patient with an indwelling urinary catheter after vascular graft surgery. Which of the following actions is most important to prevent a urinary tract infection?
A. Change the catheter every 24 hours
B. Administer IV antibiotics regularly
C. Perform meticulous perineal care
D. Encourage the patient to drink fluids regularly
C. Perform meticulous perineal care
Rationale: Meticulous perineal care is essential to reduce the risk of urinary tract infection in patients with an indwelling urinary catheter. Regular catheter care helps prevent bacterial contamination, which is a major cause of UTIs.
A patient is recovering after Open Aneurysm Repair (OAR) surgery and has developed postoperative ileus. Which of the following is the most appropriate nursing intervention to promote the return of bowel function?
A. Encourage early ambulation
B. Increase fluid intake immediately after surgery
C. Administer laxatives to promote bowel movement
D. Apply abdominal pressure to stimulate peristalsis
A. Encourage early ambulation
Rationale: Early ambulation is essential to promote the return of bowel function after surgery. It helps stimulate peristalsis and reduces the risk of developing postoperative ileus.
A patient who has undergone Open Aneurysm Repair (OAR) surgery is found to have an NG tube connected to low, intermittent suction. What is the primary purpose of this intervention?
A. To provide nutrition
B. To promote bowel function
C. To monitor for signs of intestinal perforation
D. To prevent aspiration of stomach contents
D. To prevent aspiration of stomach contents
Rationale: An NG tube connected to low, intermittent suction is used to decompress the stomach, prevent aspiration of stomach contents, and reduce pressure on the surgical site, thus helping to protect the suture lines.
A nurse is assessing a postoperative patient after OAR surgery for signs of complications. The patient reports abdominal pain, and the nurse notes absent bowel sounds, abdominal distention, and fever. What should the nurse suspect?
A. Postoperative ileus or infarction
B. Gastric ulcer or infarction
C. Bowel ischemia or infarction
D. Gastrointestinal bleeding or infarction
C. Bowel ischemia or infarction
Rationale: The absence of bowel sounds, fever, abdominal distention, and pain are indicative of bowel ischemia or infarction. Immediate reoperation is required if bowel infarction is suspected to restore blood flow and remove the infarcted tissue.
A patient post-OAR surgery has an NG tube for decompression and is being monitored for postoperative ileus. Which of the following actions should the nurse implement? (Select all that apply)
A. Record the amount and character of NG output
B. Encourage the patient to ambulate early
C. Administer laxatives to prevent constipation
D. Provide frequent oral care
E. Allow the patient to consume solid food immediately after surgery
A. Record the amount and character of NG output
B. Encourage the patient to ambulate early
D. Provide frequent oral care
Rationale: The nurse should record the NG output, encourage early ambulation to promote bowel function, and provide frequent oral care for comfort. Laxatives and solid food are not appropriate until bowel function returns.
A nurse is assessing a patient’s GI status after OAR surgery. The patient has not passed flatus for 48 hours. What is the nurse’s best course of action?
A. Encourage the patient to consume a large amount of fluids immediately
B. Monitor for signs of bowel ischemia or infarction
C. Administer antibiotics to prevent infection
D. Increase the dose of opioids for pain control
B. Monitor for signs of bowel ischemia or infarction
Rationale: The absence of flatus after 48 hours may indicate complications such as bowel ischemia or infarction, which requires careful monitoring for other signs (e.g., fever, abdominal pain). Immediate intervention may be necessary if ischemia is suspected.
A patient who underwent OAR surgery has developed a postoperative ileus. Which of the following findings is most consistent with this condition?\
A. Absent bowel sounds and bloody stools
B. Abdominal distention and passing flatus
C. Abdominal pain and fever
D. Bowel sounds present with flatulence and vomiting
B. Abdominal distention and passing flatus
Rationale: In a postoperative ileus, abdominal distention and passing flatus are signs that the bowel is beginning to function again. It is important to monitor this condition and provide support to encourage bowel movement.
A nurse is performing a neurologic assessment on a patient who has undergone aortic surgery involving the ascending aorta. Which of the following findings would require immediate notification to the healthcare provider (HCP)?
A. Normal pupil size and equal response to light
B. Facial symmetry with slight left-sided drooping
C. Weakness in the right upper extremity
D. Alert and oriented to person, place, and time
C. Weakness in the right upper extremity
Rationale: Any neurologic deficit, such as weakness in the upper extremity, indicates potential complications after surgery involving the ascending aorta and aortic arch, such as stroke or other neurologic events. Immediate notification to the HCP is necessary for further evaluation.
A nurse is performing a neurovascular assessment on a patient after aortic surgery involving the descending aorta. Which assessment finding would be most concerning?
A. Absent pedal pulses in both feet
B. Full range of motion in both lower extremities
C. Pupils responsive to light
D. Equal strength in both hands
A. Absent pedal pulses in both feet
Rationale: Absent pedal pulses in the lower extremities may indicate a vascular complication or neurovascular compromise following surgery involving the descending aorta, which requires immediate intervention and assessment.
After aortic surgery, a nurse is monitoring a patient for neurologic complications. The nurse observes that the patient is unable to move the right arm and has slurred speech. What should the nurse do first?
A. Assess the patient’s vital signs and report changes
B. Check the patient’s pupils for reaction to light
C. Document the findings and continue to monitor
D. Notify the healthcare provider immediately
D. Notify the healthcare provider immediately
Rationale: Slurred speech and inability to move the right arm are signs of possible neurologic complications such as stroke. The nurse should notify the healthcare provider immediately for further evaluation and management.
A nurse is assessing a patient’s peripheral pulses after aortic surgery involving the ascending aorta. Which pulse sites should the nurse assess?
A. Femoral, popliteal, posterior tibial, dorsalis pedis
B. Carotid, radial, temporal
C. Brachial, femoral, dorsalis pedis
D. Radial, brachial, femoral
B. Carotid, radial, temporal
Rationale: When the ascending aorta and aortic arch are involved, the nurse should assess the carotid, radial, and temporal artery pulses to monitor peripheral perfusion status.
A nurse is assessing a postoperative patient who underwent surgery on the descending aorta. Which of the following are important aspects of the nurse’s peripheral perfusion assessment? (Select all that apply.)
A. Assess the femoral, popliteal, posterior tibial, and dorsalis pedis pulses
B. Evaluate the patient’s respiratory rate
C. Measure capillary refill time
D. Check for skin temperature and color
E. Monitor the level of consciousness
A. Assess the femoral, popliteal, posterior tibial, and dorsalis pedis pulses
C. Measure capillary refill time
D. Check for skin temperature and color
Rationale: After surgery on the descending aorta, the nurse should assess the femoral, popliteal, posterior tibial, and dorsalis pedis pulses and monitor capillary refill, skin temperature, and color to ensure adequate peripheral perfusion. Level of consciousness and respiratory rate are important for overall monitoring but are not part of a peripheral perfusion assessment.
A postoperative patient is found to have absent pedal pulses, a cool and pale extremity, and reports pain in the leg. What should the nurse’s next action be?
A. Document the findings and continue to monitor
B. Reposition the patient and reassess the pulses
C. Notify the healthcare provider immediately
D. Administer pain medication and monitor closely
C. Notify the healthcare provider immediately
Rationale: Absent pulses, along with a cool, pale, mottled, and painful extremity, may indicate embolization or graft occlusion, which requires immediate attention and reoperation if identified early.
Which finding after aortic surgery would be of most concern and require immediate reporting to the healthcare provider?
A. Absence of lower extremity pulses for a short period postoperatively
B. Mild swelling in the feet
C. Absent femoral pulses, cool, pale extremity, and pain
D. Slightly delayed capillary refill in the hands
C. Absent femoral pulses, cool, pale extremity, and pain
Rationale: Absent femoral pulses along with a cool, pale extremity and pain could indicate embolization or graft occlusion, which requires immediate intervention to avoid further complications.
A nurse is assessing a postoperative patient who underwent surgery involving the descending aorta. The patient’s lower extremities have decreased pulses and are cool to the touch. What is the nurse’s next priority action?
A. Reassess pulses after repositioning the patient
B. Document the findings and continue to monitor
C. Notify the healthcare provider immediately
D. Administer IV fluids to increase circulation
C. Notify the healthcare provider immediately
Rationale: Decreased pulses and cool extremities following descending aorta surgery could be signs of embolization or graft occlusion. Immediate notification to the healthcare provider is essential for further assessment and intervention.
A nurse is monitoring a postoperative patient who underwent aortic surgery. Which of the following assessments would best evaluate the patient’s renal perfusion status in the immediate postoperative period?
A. Hourly urine output and daily BUN and serum creatinine levels
B. Oxygen saturation and lung sounds
C. Daily weight changes and abdominal girth
D. Peripheral pulses and capillary refill
A. Hourly urine output and daily BUN and serum creatinine levels
Rationale: Hourly urine output and monitoring daily BUN and serum creatinine levels are key assessments to evaluate renal perfusion status, as these provide vital information regarding kidney function and hydration.
Which of the following conditions may contribute to decreased renal perfusion following aortic surgery? (Select all that apply.)
A. Embolization of an aortic thrombus or plaque to renal arteries
B. Hypotension and dehydration
C. Prolonged aortic clamping during surgery
D. Diabetes
E. Increased urinary output
A. Embolization of an aortic thrombus or plaque to renal arteries
B. Hypotension and dehydration
C. Prolonged aortic clamping during surgery
D. Diabetes
Rationale: Embolization, hypotension, dehydration, prolonged aortic clamping, and diabetes are all risk factors for decreased renal perfusion. Increased urinary output is typically not a contributing factor to decreased perfusion.
A nurse is assessing a postoperative patient for signs of renal ischemia. Which of the following clinical findings would most likely indicate decreased renal perfusion?
A. Decreased heart rate and normal peripheral pulses
B. Increased urine output and decreased serum creatinine levels
C. Elevated blood pressure and diminished peripheral pulses
D. Decreased urine output and elevated BUN and creatinine levels
D. Decreased urine output and elevated BUN and creatinine levels
Rationale: Decreased urine output along with elevated BUN and creatinine levels are indicative of renal ischemia and decreased renal perfusion, often due to factors like hypotension or embolization of aortic thrombus.
A nurse is caring for a postoperative patient with a history of diabetes who is at risk for renal failure following aortic surgery. What is the most important intervention to monitor for signs of renal insufficiency?
A. Monitor daily blood glucose levels
B. Assess urinary output hourly and monitor BUN and creatinine levels
C. Monitor for signs of infection at the incision site
D. Assess cardiovascular status and ensure fluid resuscitation
B. Assess urinary output hourly and monitor BUN and creatinine levels
Rationale: Hourly urinary output and monitoring BUN and creatinine levels are critical for detecting renal insufficiency, especially in patients at high risk such as those with diabetes.
A nurse is educating a patient who is recovering from aortic surgery about post-operative care. Which of the following instructions is most important to include in the teaching plan regarding physical activity?
A. Resume heavy lifting after 2 weeks
B. Gradually increase activities, avoiding heavy lifting for 6 weeks
C. Avoid any physical activity for 3 months
D. Increase physical activity immediately after discharge
B. Gradually increase activities, avoiding heavy lifting for 6 weeks
Rationale: It is important for the patient to gradually increase activities and avoid heavy lifting for 6 weeks to prevent strain on the surgical site and allow for proper healing.
The nurse is teaching a patient and caregiver about post-operative care following aortic surgery. Which of the following changes should the patient and caregiver be instructed to report immediately to the healthcare provider? (Select all that apply.)
A. Redness and swelling around the surgical incision
B. Fever greater than 100°F (37.8°C)
C. Increased pain at the surgical site
D. Decreased urinary output
E. Increased peripheral pulse quality
A. Redness and swelling around the surgical incision
B. Fever greater than 100°F (37.8°C)
C. Increased pain at the surgical site
Rationale: Redness, swelling, and increased pain at the surgical site, as well as a fever greater than 100°F, are signs of possible infection or complications that require prompt medical attention. Decreased urinary output is also a concern, though not listed in the options. Increased peripheral pulse quality is usually not a concerning finding.
A male patient who recently underwent aortic surgery reports difficulty achieving an erection. The nurse should:
A. Tell the patient this is a normal consequence of the surgery and there is no treatment needed
B. Instruct the patient to avoid sexual activity until after the 6-week recovery period
C. Advise the patient to increase physical activity and reduce stress
D. Suggest a referral to a urologist and counseling if necessary
D. Suggest a referral to a urologist and counseling if necessary
Rationale: Sexual problems, such as erectile dysfunction, are common after aortic surgery. A referral to a urologist and possibly counseling can be beneficial in addressing these issues.
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that the aneurysm has ruptured?
a. Rapid onset of shortness of breath and hemoptysis
b. Sudden low back pain and bruising along the flank
c. Patchy blue mottling on feet and toes and rest pain
d. Gradually increasing substernal chest pain and diaphoresis
b. Sudden low back pain and bruising along the flank
Which nursing interventions are the priority 8 hours after an abdominal aortic aneurysm repair?
a. Assessing nutrition status and diet preferences
b. Starting IV heparin and monitoring anticoagulation
c. Administering IV fluids and watching kidney function
d. Elevating the legs and applying compression stockings
c. Administering IV fluids and watching kidney function
Which risk factor would the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm?
a. Male gender
b. Hypertension
c. Age over 60 years
d. Family history of vascular disease
b. Hypertension
Rationale: Hypertension can potentially be managed to decrease the patient‘s risk for further expansion of the aneurysm. Male gender, older age, and family history are not modifiable risk factors.
Which finding on a patient‘s nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm?
a. Low back pain
b. Difficulty swallowing
c. Abdominal tenderness
d. Changes in bowel habits
b. Difficulty swallowing
Rationale: Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms would be expected in patients with abdominal aortic aneurysms.
A patient had an open surgical repair of an abdominal aortic aneurysm earlier today. The patient‘s total urinary output for the past 2 hours was 45 mL. What would the nurse anticipate will be prescribed?
a. Hemoglobin count
b. Increased IV fluids
c. Additional antibiotics
d. Serum creatinine level
b. Increased IV fluids
Rationale: The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient‘s decreased urinary output.
Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm?
a. Record hourly chest tube drainage.
b. Monitor fluid intake and urine output.
c. Assess the abdominal incision for redness.
d. Counsel the patient to plan for a long recovery time.
b. Monitor fluid intake and urine output.
Rationale: Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first?
a. Draw blood for laboratory testing.
b. Check the patient‘s blood pressure.
c. Assess the patient for an abdominal bruit.
d. Determine any family history of heart disease.
b. Check the patient‘s blood pressure.
Rationale: Because the patient appears to be experiencing aortic dissection, the nurse‘s first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action would the nurse take first?
a. Wrap both legs in a warming blanket.
b. Notify the surgeon and anesthesiologist.
c. Document the findings and recheck in 15 minutes.
d. Review the preoperative assessment in the health record.
b. Notify the surgeon and anesthesiologist.
Rationale: Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings would be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse already would know whether pulses were present before surgery. Because the patient‘s symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient‘s legs.
When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider?
a. Presence of flatus
b. Hypoactive bowel sounds
c. Maroon-colored liquid stool
d. Abdominal pain with palpation
c. Maroon-colored liquid stool
Rationale: Loose, bloody (maroon-colored) stools at this time may indicate intestinal ischemia or infarction and would be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.
Which intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously could the nurse delegate to assistive personnel (AP)?
a. Monitor the quality and presence of the pedal pulses.
b. Teach the patient the signs of possible wound infection.
c. Check the lower extremities for strength and movement.
d. Help the patient to use a pillow to splint while coughing.
d. Help the patient to use a pillow to splint while coughing.
Rationale: Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement would be done by RNs.
