A patient has just undergone an abdominal aortic aneurysm repair. ...

[ts19998]

A patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing and a wrist restraint is ap-plied after an order is received.
 
  Later, the patient reports tingling and numbness in the fingers and hand. Which actions should the nurse take? (Select all that apply.) a. Remove the restraint immediately.
  b. Remind the patient this will decrease with time.
  c. Notify the health care provider.
  d. Medicate the patient for pain.
  e. Stay with the patient.

Question 2

A nurse is assisting the respiratory therapist with a physical assessment of a client who is being treated for pleural effusion at a health care facility.
 
  The therapist needs the client to exhale additional air in order to determine the client's expiratory reserve volume. What instruction should the nurse give the client? A) Expand the thoracic cavity.
  B) Relax the respiratory muscles.
  C) Contract the abdominal muscles.
  D) Elevate the ribs and sternum.

[deja]

Answer to Question 1

A, C, E
If a patient has altered neurovascular status (tingling and numbness) remove the restraint imme-diately, stay with the patient, and notify the health care provider. Tingling and numbness will not decrease with time; it will continue to cause damage. The patient does not need pain medication; the restraint is too tight and needs to be removed.

Answer to Question 2

C
Feedback:
The nurse should instruct the client to contract the abdominal muscles to exhale additional air. A person can forcibly exhale additional air by contracting abdominal muscles such as the rectus abdominis, transverse abdominis, and external and internal obliques. The client elevates the ribs and sternum and expands the thoracic cavity during inspiration. The client relaxes the respiratory muscles during normal expiration.

[ts19998]

Excellent

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