Page 1763 - Saunders Comprehensive Review For NCLEX-RN

Test-Taking Strategy: Focus on the subject, expected outcomes following
aortoiliac bypass graft surgery. Venous complications from immobilization resulting
from surgery would not be apparent within 4 hours, so eliminate option 4. From the
remaining options, note that the pedal pulse is unchanged from admission and think
about the effects of sudden reperfusion in an ischemic limb. There would be redness
from new blood flow and edema from the sudden change in pressure in the blood
vessels.
Level of Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Vascular disorders
Priority Concepts: Clinical Judgment; Perfusion
Reference: Lewis et al. (2014), p. 839.

621. Answer: 3

Rationale: Following pericardiocentesis, the client usually expresses immediate
relief. Heart sounds are no longer muffled or distant and blood pressure increases.
Distended neck veins are a sign of increased venous pressure, which occurs with
cardiac tamponade.
Test-Taking Strategy: Focus on the subject, expected outcome following
pericardiocentesis, and note the strategic word, effective. Successful therapy is
measured by the disappearance of the original signs and symptoms of cardiac
tamponade. This will direct you to the correct option.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Cardiovascular: Cardiac Tamponade
Priority Concepts: Evidence; Perfusion
Reference: Lewis et al. (2014), pp. 815-816.

622. Answer: 4

Rationale: Following abdominal aortic aneurysm resection or repair, the nurse
monitors the client for signs of acute kidney injury. Acute kidney injury can occur
because often much blood is lost during the surgery and, depending on the
aneurysm location, the renal arteries may be hypoperfused for a short period during
surgery. Normal reference levels are BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and
creatinine 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) for males and 0.5 to 1.1 mg/dL (44 to
97 mcmol/L) for females. Continuing to monitor urine output or checking other
parameters can wait. Urine output lower than 30 mL/hr is reported to the PHCP for
urgent treatment
Test-Taking Strategy: Note the strategic word, priority. Focus on the data in the
question and the abnormal assessment data. This question indicates elevations in
blood urea nitrogen and creatinine levels and a significant drop in hourly urine

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