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A nurse is caring for a client who is 1 hr postoperative following an AAA. Which of the following findings can indicate shock and should be reported to the provider?

A. Blood pressure of 100/70 mmHg
B. Respiratory rate of 18 breaths per minute
C. Urine output of 30 mL/hour
D. Heart rate of 120 beats per minute

User Roosh
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1 Answer

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Final answer:

The finding of a heart rate of 120 beats per minute post abdominal aortic aneurysm (AAA) surgery should be reported to the healthcare provider as it may indicate hypovolemic shock, a condition where decreased blood volume leads to inadequate oxygenation of tissues.

Step-by-step explanation:

A nurse should report any findings that could indicate shock in a postoperative patient. After an abdominal aortic aneurysm (AAA) surgery, it is crucial to monitor the patient for signs of shock due to potential complications such as bleeding or vascular compromise. Among the options given, a heart rate of 120 beats per minute can be a sign of shock, especially if it is tachycardic in nature, as it could indicate the body's response to hypovolemia or reduced blood volume circulating in the system. Shock is characterized by various symptoms, including a rapid heart rate, low blood pressure, reduced urine output, confusion, and in some cases, even normal blood pressure readings. Therefore, in this context, Option D (heart rate of 120 beats per minute) should be reported to the provider, as this may signal hypovolemic shock requiring immediate medical attention.

Urine output of less than 30 mL/hour is another indicator; however, if it's within the first few hours post-operation, it may not be an immediate sign of shock but rather a response to the surgery or anesthesia and should still be closely monitored.

User Aurimas
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