Test question - how would you answer?

[PJMommy]

In the first 24 hours post-op abdominal aneurysm repair, what is your priority nursing intervention?

1 - Pain management

2 - Blood pressure monitoring

3 - Wound assessment

4 - Patient ambulation

What would you choose -- and please tell me why...

I'll give you the "correct" answer later -- as well as what I answered...obviously not correctly! :)

[lisaloulou]

My answer is PAIN management. OW OW OW OW OW. This is one big ouchy surgery.

[loriy]

I definitely go with B/P monitoring. When in doubt always go back to ABCs - airway, breathing, circulation. True that pain can RAISE the B/P but in that case you then evaluate the pain. What you're looking for specifically with B/P is the potential for a ruptured aorta - which would cause decreased B/P. Like an earlier writer stated - what could kill this patient?

[dcs]

Think physiology first, safety second which includes comfort. Pain management bridges physiology to safety. My two cents.

[RNConnieF]

Think Maslow, then nursing process. Physical well being before psychological needs. BOP is physical, pain is psychological (according to Maslow). Now thing nursing process, 9/10 times assessment is prior to intervention. Short NC review. :)

[rngrad2009]

i would say b. I learned that in any case, first priorities always involve your ABC's. Your blood pressure is the measurement of the circulatory system.

[MelH]

I am going to say pain management. I say this b/c your priority nurisng assessment during the immediate post op would be bp monitoring. pain incr. bp so I would say this. I am kinda stuck b/c ambulation is important also but it says priority and there are other things that you can do to get the pts blood moving while in bed. So I will say pain management. AAAAAHHHHHHHHHHHHH--these questions are sooooo tricky!!!!!!!!!!!!!!!!!

[PennyLane, RN]

We learned you go in the following order of importance:

Ventilation

Infusion

Perfusion

Pain

So BP monitoring would be under Infusion, and above pain or ambulation, or the wound (pain, infection).

[EMcDLPN]

now i'm very curious. read the question carefully... first nursing intervention...? b/p is an assesment leading you to different interventions. emphasis should be on b/p, but i say intervention would be pain control. lets see if my few years experience is correct?

[NYCRN16]

I would say B/P. Remember students even if its just for NCLEX purposes:

Pain is a PSYCHOSOCIAL need and is ALWAYS a lesser priority than a PHYSIOLOGICAL need.

Infection is important, but that is NOT an immediate need, and you shouldnt be concerned with infection as your first priority with an unstable/potentially unstable patient.

B/P would be your first priority. If that AAA ruptures, you are in deep doo doo!

:)

[FullMoonMadness]

Always go with ABC and then Maslow. I'm guessing B/P. Now I'll go back and see if Im right.

[magikbear2]

umm .. I'd go pain mgmt. Pain is considered the5th vital sign now

[MelH]

SO WHAT IS THE ANSWER???? :eek: :eek: :eek: :