# A nurse is caring for a client with a thoracic aortic aneurysm who is scheduled for surgical repair. Which nursing intervention should be the priority in the preoperative period?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=177034  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a client with a thoracic aortic aneurysm who is scheduled for surgical repair. Which nursing intervention should be the priority in the preoperative period?

## 보기

1. Administer prescribed antihypertensive medications to maintain blood pressure below 120/80 mmHg
2. Encourage deep breathing exercises and use of incentive spirometry every 2 hours
3. Monitor blood pressure closely and avoid activities that increase intrathoracic pressure **✔ 정답**
4. Provide detailed education about the surgical procedure and postoperative expectations

**정답: 3**

## 해설

Monitoring blood pressure and avoiding activities that increase intrathoracic pressure is the priority to prevent aneurysm rupture. Other interventions are important but secondary to immediate rupture prevention.

## 심화 해설

Understanding the Priority: Preoperative Care for Thoracic Aortic Aneurysm

The core of this question lies in recognizing the most immediate physiological threat to a client with a thoracic aortic aneurysm. An aneurysm is a weakened, bulging section of the arterial wall. The primary danger in the preoperative period is rupture or dissection, which is often a fatal event. The foundational principle guiding all nursing interventions is to minimize wall stress on the aorta. Wall stress is directly influenced by two key factors: blood pressure and the force of cardiac contraction. Therefore, the highest priority nursing action is the one that most directly controls these factors.

Analysis of the Correct Answer: Option 3

Monitoring blood pressure closely and avoiding activities that increase intrathoracic pressure is the priority intervention. This option directly addresses the pathophysiology of aneurysm rupture. According to the principles of hemodynamic management, controlling mean arterial pressure and reducing shearing forces on the aortic wall are critical to preventing rupture . Activities that increase intrathoracic pressure, such as straining during a bowel movement, coughing forcefully, or vomiting, perform a Valsalva maneuver. This maneuver transiently increases intrathoracic pressure, which is transmitted to the aorta, causing a sharp spike in blood pressure and wall stress. By closely monitoring blood pressure, the nurse can detect and address hypertension, a primary driver of wall stress, before it reaches a critical point. This proactive, physiology-based intervention is the cornerstone of preoperative safety.

Analysis of the Incorrect Answers

Option 1: Administer prescribed antihypertensive medications to maintain blood pressure below 120/80 mmHg.

While blood pressure control is essential, this option contains a critical flaw. A rigid target of "120/80 mmHg" is not a universal goal and can be dangerous. Aggressive lowering of blood pressure can lead to hypotension, causing inadequate perfusion to vital organs, including the brain, heart, and kidneys. The goal is individualized, often aiming for a systolic pressure that minimizes aortic wall stress without compromising end-organ perfusion. The priority is the nurse's continuous assessment and prevention of pressure spikes, not the administration of medication to a potentially harmful fixed number.

Option 2: Encourage deep breathing exercises and use of incentive spirometry every 2 hours.

This is an important postoperative intervention to prevent atelectasis and pneumonia. In the preoperative period, teaching these exercises is a component of prehabilitation, a multimodal strategy to improve a patient's physiological and psychological reserve before surgery . While valuable for reducing postoperative pulmonary complications, it does not address the immediate, life-threatening risk of aneurysm rupture. In the hierarchy of needs, a physiological risk of fatal hemorrhage takes precedence over preparatory education for a future complication.

Option 4: Provide detailed education about the surgical procedure and postoperative expectations.

Preoperative education is a vital nursing role that reduces anxiety and improves adherence. It is a key psychological component of prehabilitation programs . However, a client who is experiencing a spike in blood pressure from pain or anxiety is at immediate risk of rupture. The nurse must first ensure the client's physiological stability. Managing the physical environment to reduce stressors and monitoring the body's response is a more urgent priority than providing detailed procedural information. Education can and should occur concurrently, but only after immediate safety is ensured.

Integrating the Evidence into Clinical Judgment

Modern perioperative care for complex cardiovascular patients, as highlighted in the provided evidence, emphasizes a shift toward personalized risk mitigation. The concept of prehabilitation involves assessing and optimizing a patient's vulnerabilities, including frailty and sarcopenia, before surgery [1,2]. While education and respiratory exercises are components of this, the immediate preoperative nursing priority remains grounded in basic, life-saving physiology. The evidence discussing perioperative advances underscores the importance of "personalized hemodynamic management" to reduce complications . For a nurse at the bedside, this translates directly into the actions described in option 3: meticulous, continuous monitoring and the creation of a therapeutic environment that actively avoids hemodynamic stressors. This is not just a task; it is the clinical application of the principle that reducing aortic wall stress is the single most effective strategy to keep the client alive until surgical repair can be performed.

## 임상 시나리오

A client with a thoracic aortic aneurysm is admitted for surgical repair. The nurse understands that the primary preoperative goal is to prevent rupture by minimizing aortic wall stress. The nurse's first action is to establish continuous hemodynamic monitoring, focusing on blood pressure trends and heart rate. The client is placed on bed rest with the head of the bed elevated no more than 30 degrees to avoid sharp turns or flexion that could compress the aorta.

The nurse instructs the client to avoid all activities that trigger a Valsalva maneuver. This includes teaching the client to exhale gently when turning or moving, to avoid holding their breath, and to use a stool softener to prevent straining during bowel movements. The call light is placed within reach, and the nurse emphasizes that the client should call for assistance before getting out of bed. Anti-emetics are administered as prescribed to prevent vomiting, another potent trigger for increased intrathoracic pressure.

Pain and anxiety are managed aggressively, as both can stimulate the sympathetic nervous system, leading to elevated blood pressure and heart rate. The nurse maintains a quiet, calm environment and administers prescribed analgesic and anxiolytic agents carefully, monitoring for their effect on respiratory rate and blood pressure. Any sudden onset of severe, ripping chest or back pain is reported immediately as a potential sign of dissection or rupture, requiring rapid intervention.

## 핵심 개념

- **Valsalva maneuver** — Forced expiration against a closed glottis, increasing intrathoracic pressure and causing a transient spike in blood pressure that elevates aortic wall stress.
- **Aortic wall stress** — The force exerted on the weakened arterial wall, determined primarily by blood pressure and cardiac contractility; minimizing it is key to preventing aneurysm rupture.
- **Thoracic aortic aneurysm** — A localized dilation or bulging of the thoracic portion of the aorta, carrying a high risk of life-threatening rupture or dissection.
- **Preoperative priority** — The nursing action that addresses the most immediate life-threatening physiological risk, in this case, preventing aortic rupture by ensuring hemodynamic stability.
- **Intrathoracic pressure** — The pressure within the thoracic cavity; increases during straining, coughing, or vomiting, which can be directly transmitted to the thoracic aorta.

## 같은 주제 문제

- [A nurse is assessing a 70-year-old male client with a known 5.2 cm abdominal aortic aneury…](https://mymerci.kr/pages/nclex_q.php?qn_id=177029)
- [A nurse is assessing a 72-year-old female client who presents to the emergency department …](https://mymerci.kr/pages/nclex_q.php?qn_id=177030)
- [A 65-year-old male is rushed to the emergency department with severe, tearing abdominal pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=177031)
- [A 54-year-old male client presents to the emergency department with severe abdominal pain …](https://mymerci.kr/pages/nclex_q.php?qn_id=177033)
- [The nurse is evaluating a client and determines that which of these findings requires the …](https://mymerci.kr/pages/nclex_q.php?qn_id=177036)
- [A nurse is caring for a 45-year-old female client with suspected thoracic aortic aneurysm …](https://mymerci.kr/pages/nclex_q.php?qn_id=177037)
- [Which of the following findings is the most critical for the nurse to report to the health…](https://mymerci.kr/pages/nclex_q.php?qn_id=177038)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._