Question

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.

Answer 1

The nurse should measure the abdominal girth and check pulses.

Step-by-step explanation:

The nurse's best action in this situation would be to measure the abdominal girth and check pulses. Coolness of the extremities and a bloated feeling in the abdomen can be signs of decreased blood flow, which may indicate a complication following surgical repair of an abdominal aortic aneurysm (AAA). By measuring the abdominal girth and checking pulses, the nurse can assess for any changes in vascular status and address them appropriately.