A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern?

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11ecbb05_c946_bf01_b433_9dcc7cdbae12_MD0009_00 Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair. Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to decreased renal perfusion and potential kidney injury. The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine output. Urine output should be at least 30 mL/hr. This client should have an output of at least 120 mL of urine in a 4-hour period. (Option A) Diminished breath sounds in the lung bases are a common occurrence after surgery, especially in a client who has an abdominal incision that is painful with deep inspiration. The nurse should medicate the client for pain and encourage coughing, deep breathing, and use of an incentive spirometer. (Option B) Hypoactive bowel sounds are typical after abdominal surgery as the bowel has been handled and manipulated. Clients often have a nasogastric tube for suction until bowel sounds return. The nurse should continue to monitor for bowel sounds and the presence of flatus. (Option D) A decreased or absent pulse, together with cool, pale, or mottled extremities, would be cause for concern. This client has warm extremities. Pulses should be compared with preoperative status and can be verified with a Doppler if needed. Educational objective: The nurse should carefully monitor renal status in a client who has had abdominal aortic aneurysm repair. BUN, creatinine, and urine output should be assessed. Urine output of at least 30 mL/hr is expected.

A Client Is 48 Hours Post Abdominal Aneurysm Repair