The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation? ? A. Pedal pulses regular ? B. Urinary output 20mL in the past hour ? C. Blood pressure 108/50 ? D. Oxygen saturation 97% 2. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider? ? A. Diet pattern ? B. Mobility ? C. Fluid intake ? D. Sexual function 3. Which one of the following statements is correct when measuring the client for crutches? ? A. A distance of five fingerbreadths should exist between the top of the crutch and the axilla. ? B. The nurse should measure three inches between the top of the crutch and the axilla. ? C. The client’s elbows should be flexed at a 10º angle. ? D. The crutches should be extended 8 to 10 inches from the side of the foot.
The Correct Answer and Explanation is :
Let’s address each question in turn:
1. Postoperative Assessment Following Abdominal Aneurysm Repair
Question: e client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation? A. dal pulses regular
- Briry output 20 mL in the past hour
- C. Bd essure 108/50
- D. Oxygsaration 97%
Correct Anr: B. Urinary outp 20 mL in the past hour
*Explanation:*onitoring urinaryutput is crucial after abdominal aneurysm repair, as it serves as an indicator of renal perfusion and function. A urinary output o mL in the past hour is below the expected minimum of 0.5 mL/kg/hour, which is approximately 30-40 mL per hour for an average adult. Decreased urine outpan be an early sign of acute kidney injury (AKI), a known complication in the postoperative period. Factors contributing tI include hypotension, hypovolemia, or renal artery clamping during surgery. Early detection and manant are vital to prevent progression to severe renal dysfunction. (pmc.ncbi.nlm.nih.gov)
The other findings—regular pedal pulses, blood pressure of 108/50 mmHg, and oxygen saturation of 97%—are within acceptable ranges for a postoperative patiend do not immediately indicate complications. However, all vital signs should be contously monitored to ensure patient stability.
2. Factors in Bowel and Bladder Retrainingor a Client with Paraplegia
Question: The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the followins n a factor for nse to consr?- A. Diet patt -. Mobility
- C. Fd intake
- D. Sexuafunction
Correcnswer: D. Sexualunction
Explanation:
Bowel and bladder retraining programs for clients with paraplegia focus on establishing regular elimination patterns and preventing complications such as constipation, incontinence, andrinary tract infections. Key facrs to consider includ
- Diet Pattern: A high-fiber diet aids in preventing constipation by promoting rular bowel movement (christopherree.org)
- Mobility: Physical activity, even pave movements, can stilate bowel function and assist in bladder emptying. Limited mobility may necessitate alternative strategies to facilitate elimination. Fluid Intake: eate hydration is essential to maintain urinary health and prevent complications such as urinary tract infections and kidney stones. (physio-pedia.com)
While sexual function is an important aspect of overall quality of life and should be addressed in the compreheve care of a client with paraplegia, it is not direct related to the processes of bowel and bladder retraining. Therefore, among the optionsovid, sexual function is not a primary factor for the nurse to consider in this specific context.3Proper Measurement for Crutches*
Question: Which one of the following statements coect when measuring the client for crutches?
- A. A dincof five fingerbreadths should exist between the top of the crutch and the ala.
- B. The nurse ould measure three inches between the top of the crutch and the axilla.
- C. The clies elbows should bflexed at a 10º angle.
- D. The crutches should be extended 8 to 10 inches from the side he foot.
Correct Answer: The nurse should measu three inches between the top of the crutch and the axilla.
Explanation:
Proper crutch fitting is essential to ensure safetomfort, and to prevent nerve damage. The correct method includes:
- Axillary Space: There should be a gap of apprmately 2 to 3 inches (out 2 to 3 fingerbreadths) between the top of the crutch and the axilla. This space preventsssure on the axillary nerves and blood vessels, reducing the r of nerve compression injies.
- Elbow Flexion: The elbows should be flexed at an angle of about 20 to 30 degrees when holding the handgr This allows for optimal leverage and comfort during ambulation.
- **Crutch Placement:Wn standing, the crutch tips should be positioned approximately 6 inches lateral and 6 inches anteriorthe toes. This placement provides a stable base of support and facilitates a natural gait pattern.
Option A suggests a of five fingerbreadths, which may be excessive and could compromise stability. Option C indicates a 10º elbow flexion, which infficient and may lead to inadequate leverage and increased fatigue. Option D recends extending the crutches 8 to 10 inches from the side of the foot, which is too far and may cause instability.
Therefore, option B is the correct statement regarding proper crutch measurement.