Miami Dade College, Miami Answer Key point.

Question 1 See full question 13s A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention? You Selected: • Prepare the client for surgical intervention Correct response: • Prepare the client for surgical intervention Explanation: When the vessel ruptures, prompt surgery is required for it’s repair. Antihypertensive medications and beta-adrenergic blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm. Remediation: • Aneurysm (thoracic aortic) Question 2 See full question 45s After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse’s priority action? You Selected: • Assess the groin site Correct response: • Assess the groin site Explanation:Assessment of the groin site is the priority. This establishes the source of the blood, and determines how much blood has been lost. The goal is to stop the bleeding. The nurse would call for help if needed after the assessment of the situation. After determining the extent of the bleeding, vital sign assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause re-bleeding. Remediation: • Cardiac catheterization Question 3 See full question 33s The nurse is ambulating a client. The client experiences chest pain after ambulating 50 feet. What is the nurse’s priority intervention? You Selected: • Sit the client down Correct response: • Sit the client down Explanation: The priority is to decrease oxygen consumption by sitting this client down. When the client’s condition is stabilized, he can be returned to bed. An ECG can be obtained after the client is sitting down, and the ordered sublingual nitroglycerin could be administered. Remediation: • Ambulation, progressive