A nurse is recovering a client who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The client develops coolness of the extremities and reports a bloated feeling in the abdomen. What is the nurse's best action?
a. Measure the abdominal girth and check pulses.
b. Raise the head of the bed to 90 degrees.
c. Assess cardiac output and blood pressure.
d. Auscultate and then palpate the abdomen.
A
Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue color in the flanks, and severe pain. Elevating the head of the bed would place too much pressure on the surgical site. The other two options are not warranted.
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