test question

  1. 1.the client had an abdominal aortic aneursym repair two days ago. Which intervention shoudl the nurse implement first?
    a.assess the client bowel sounds
    b. administer iv prophylactic antibiotic
    c.encourage the client to splint the incision
    d.ambulate the client in the room with assisstance

    2.Which assessment data would require immediate intervention by the nurse for the client who is 6 hrs post-op abdominal aortic aneurysm repair?
    a. absent bilateral pedial pulses
    b.complaints of pain at the site of the incision
    c.distended tender abdomin
    d.an elevated temperature of 100*F.

    I was going with d on the first one and a in the second one. Any suggestions would be greatly appreciated. Thanks
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  2. 13 Comments

  3. by   09RN
    Quote from leagirl36
    1.the client had an abdominal aortic aneursym repair two days ago. Which intervention shoudl the nurse implement first?
    a.assess the client bowel sounds
    b. administer iv prophylactic antibiotic
    c.encourage the client to splint the incision
    d.ambulate the client in the room with assisstance

    2.Which assessment data would require immediate intervention by the nurse for the client who is 6 hrs post-op abdominal aortic aneurysm repair?
    a. absent bilateral pedial pulses
    b.complaints of pain at the site of the incision
    c.distended tender abdomin
    d.an elevated temperature of 100*F.

    I was going with d on the first one and a in the second one. Any suggestions would be greatly appreciated. Thanks
    For the first one I would answer A. On our tests you always assess before you do anything else.

    For question 2 I would say : A. Absent pulse not a good thing. B and C I think you be normal and D 100 isnt considered a fever.

    Im just in my first semester so Im not sure how right I will be. When you find out please post.
  4. by   twinkerrs
    I say "A" for number one and "C" for the second, due to the fact that this could mean internal bleeding.
  5. by   Conrad283
    Quote from leagirl36
    1.the client had an abdominal aortic aneursym repair two days ago. Which intervention shoudl the nurse implement first?
    a.assess the client bowel sounds
    b. administer iv prophylactic antibiotic
    c.encourage the client to splint the incision
    d.ambulate the client in the room with assisstance

    2.Which assessment data would require immediate intervention by the nurse for the client who is 6 hrs post-op abdominal aortic aneurysm repair?
    a. absent bilateral pedial pulses
    b.complaints of pain at the site of the incision
    c.distended tender abdomin
    d.an elevated temperature of 100*F.

    I was going with d on the first one and a in the second one. Any suggestions would be greatly appreciated. Thanks
    I would assess first, so my answer to the first question would be A.
    No matter what the situ, absent pulses is bad. A for number two
  6. by   Conrad283
    Quote from twinkerrs
    "C" for the second, due to the fact that this could mean internal bleeding.
    But they're six hours post-op for abdominal surgery. They're going to been sore and swollen. If the question asked a couple days post-op, I think that if they're distended it's not a good thing, but I think it's expected six hours post-op
  7. by   beth66335
    Quote from leagirl36
    1.the client had an abdominal aortic aneursym repair two days ago. Which intervention shoudl the nurse implement first?
    a.assess the client bowel sounds
    b. administer iv prophylactic antibiotic
    c.encourage the client to splint the incision
    d.ambulate the client in the room with assistance

    2.Which assessment data would require immediate intervention by the nurse for the client who is 6 hrs post-op abdominal aortic aneurysm repair?
    a. absent bilateral pedal pulses
    b.complaints of pain at the site of the incision
    c.distended tender abdomen
    d.an elevated temperature of 100*F.

    I was going with d on the first one and a in the second one. Any suggestions would be greatly appreciated. Thanks
    The first one is A. Two days post-op is enough time for a sleepy bowel to wake up and the Aorta feeds everything in the lower part of your body including the bowels.B would have been done pre-op and the others aren't as important as A.

    The second one is C. The abdomen should be tender from the incision, but not distended this could = free blood. A is a concern too, but not more immediate than C. B is a lower priority and D is not considered a fever in most hospitals.
  8. by   Reno1978
    Both are A. In regards to the 2nd question, absent bilateral pedal pulses are more of an immediate concern. Think about your ABCs.
  9. by   zenurse
    For #1, the question asks for an intervention--is it acceptable to answer A, which is an assessment? I'm pretty new to all this, but that might throw me off.
  10. by   may1206
    i think both A's
  11. by   Daytonite
    1. the client had an abdominal aortic aneurysm repair two days ago. which intervention should the nurse implement first?
    a. assess the client bowel sounds
    b. administer iv prophylactic antibiotic
    c. encourage the client to splint the incision
    d. ambulate the client in the room with assistance
    "a". you are always looking for signs and symptoms of complications. an ileus or bowel rupture are a complication of this surgery.
    2. which assessment data would require immediate intervention by the nurse for the client who is 6 hours post-op abdominal aortic aneurysm repair?
    a. absent bilateral pedal pulses
    b. complaints of pain at the site of the incision
    c. distended tender abdomen
    an elevated temperature of 100 degrees f.
    "c". a distended tender abdomen indicates hemorrhage and most likely shock due to rupture of the aneurysm repair and will require immediate notification of the doctor and likely surgical intervention. absent bilateral pulses would indicate that there is a graft occlusion, but this is not a surgical emergency.
    Last edit by Daytonite on Nov 4, '07
  12. by   Conrad283
    Quote from leagirl36
    2.Which assessment data would require immediate intervention by the nurse for the client who is 6 hrs post-op abdominal aortic aneurysm repair?
    a. absent bilateral pedial pulses
    b.complaints of pain at the site of the incision
    c.distended tender abdomin
    d.an elevated temperature of 100*F.

    I asked my teacher this question and she said without a doubt it's absent bilateral pedal pulses because a distended tender abdomen is expected after surgery. If they were re-bleeding they would have intense back and abdominal pain.
  13. by   GAA30
    They are both A. An aneurysm can cause hypoactive bowel sounds and we need to ensure that they are active. The second question is A because of the absent pulses.

    ABC"S
  14. by   luvleee
    I say A for both

    my rationale is...
    post-operatively, could have paralytic ileus (the other answers are less on the hierarchy)
    and Airway, Circulation, Breating (#2 - absent bilateral pulses!! - impaired circulation!!!)

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