A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
a. Administer pain medication.
b. Assess distal pulses every 10 minutes.
c. Have the client sign a surgical consent.
d. Notify the Rapid Response Team.
e. Take vital signs every 10 minutes.v
ANS: B, D, E
This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client's blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.
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