The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up?

Question

Quizplus · Accepted Answer

Abdominal aortic aneurysms are surgically repaired when they measure about 6 cm or are causing symptoms. Repair can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm with synthetic graft placement. The client must be monitored postoperatively for graft leakage and hemodynamic stability. Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the formation of graft thrombosis. Signs of graft leakage include a decreasing blood pressure and increasing pulse rate. (Option A) Following surgery, the client will experience abdominal tenderness. The abdomen should remain soft and nondistended. A rigid, distended abdomen would indicate possible blood (graft leakage) in the cavity. (Option C) Pain is an expected finding following abdominal surgery. However, increasing pain that is not relieved by medication can indicate possible graft leakage and should be investigated. (Option D) During abdominal surgeries, it is customary to insert a nasogastric tube that is left in place during the immediate postoperative period. Green bile-colored drainage would be expected. Bloody drainage would cause concern. Educational objective: Following repair of an abdominal aortic aneurysm, hemodynamic stability is a priority. Prolonged hypotension can lead to graft thrombosis. A falling blood pressure and rising pulse rate can also signify graft leakage.

The Nurse Cares for a Client Who Had an Abdominal