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Zorluk: ZorReduction of Risk Potential

A nurse is assessing a client who is 12 hours post-operative following an open surgical repair of an abdominal aortic aneurysm (AAA). Which of the following findings indicate a potential post-operative complication requiring immediate intervention? (Select all that apply.)

  1. A total urine output of 35 mL over the past two hoursCevap
  2. A sudden increase in blood pressure to 185/105 mm HgCevap
  3. C
    Arterial blood gas results showing a pH of 7.37 and a PaCO2 of 42 mm Hg
  4. New-onset absence of dorsalis pedis pulses that were previously palpableCevap
  5. E
    Core body temperature of 99.2°F (37.3°C)
  6. F
    Hypoactive bowel sounds in all four abdominal quadrants

Cevap

The findings requiring immediate intervention are a total urine output of 35 mL over the past two hours, a sudden increase in blood pressure to 185/105 mm Hg, and the new-onset absence of previously palpable dorsalis pedis pulses.
The correct findings indicate life-threatening complications of an open AAA repair. A urine output of 35 mL over two hours (average 17.5 mL/hr) indicates acute kidney injury, likely due to prolonged aortic cross-clamping. Severe hypertension (185/105 mm Hg) places excessive stress on the arterial anastomosis and significantly increases the risk of graft rupture. A new-onset absence of pedal pulses signifies acute graft thrombosis or arterial occlusion, requiring immediate surgical evaluation.

Adım Adım Çözüm

1
Analyze the client's surgical history and time frame.
The client is 12 hours post-operative following an open AAA repair.
This specific time frame carries a high risk for graft occlusion, graft rupture, and acute kidney injury secondary to aortic cross-clamping.
2
Evaluate the renal and cardiovascular assessment findings.
Urine output is 17.5 mL/hr, blood pressure is severely elevated at 185/105 mm Hg, and pedal pulses are newly absent.
Decreased urine output suggests renal ischemia. Severe hypertension places dangerous pressure on the aortic anastomosis. Absent pulses indicate graft thrombosis.
3
Differentiate between expected physiological responses and pathological complications.
Normal ABGs, a mild temperature elevation of 99.2°F, and hypoactive bowel sounds are identified as expected post-operative findings.
Recognizing expected findings prevents unnecessary interventions and correctly prioritizes life-threatening emergencies.

Anahtar Kavram

Post-operative monitoring and complication detection following an open abdominal aortic aneurysm (AAA) repair.
Tahmini Süre:1m 30s
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Konular

Reduction of Risk Potential

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