The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an IV infusion of maintenance fluid at a rate of 150 mL/hr, unchanged from the last 10 hours. The client's urine output for the last 3 hours has been 90ml, 50mL, and 24mL. Which nursing action is the priority?

A. A 4 cm aneurysm in a young patient, especially one as young as 28 years old, would typically be monitored more closely rather than immediately undergoing surgery. Surgical intervention is more commonly considered for larger aneurysms or in cases where there are other risk factors or symptoms present.
B. Marfan's syndrome is a genetic disorder that affects connective tissue and is associated with a higher risk of developing aortic aneurysms, including abdominal aortic aneurysms. Patients with Marfan's syndrome are at a greater risk of aneurysm growth and rupture due to the weakened connective tissue.
C. Hypertension is a significant risk factor for the growth and rupture of an AAA. While managing hypertension with beta-blockers is important in controlling the risk, the presence of hypertension alone does not necessarily indicate that surgical intervention is immediately necessary

D. While patient concerns and anxiety about their condition are valid and important, expressing concern about dying does not directly determine the need for surgical intervention. Surgical decisions are based on objective clinical criteria, such as the size of the aneurysm, growth rate, symptoms, and overall health of the patient.

A. Monitoring the client’s back pain is important to assess the severity and progression of symptoms, especially since AAA can be associated with back pain. However, this intervention alone is not sufficient given the severity of the symptoms and the critical nature of the condition.
B. Analyzing the complete blood count (CBC) results is important, especially in the context of potential bleeding or internal hemorrhage. The patient's hemoglobin is slightly low (11 g/dL compared to the normal range of 14 to 18 g/dL), which could indicate bleeding or anemia.
C. Given the presence of a 4 cm AAA and symptoms that could indicate a worsening condition, preparing the client for emergency surgery may be necessary, especially if there is concern about rupture or if the aneurysm is symptomatic. Surgery is often required for larger or symptomatic AAAs to prevent rupture and manage the risk.
D. If the client shows signs of significant bleeding or if further testing indicates a need for blood replacement, obtaining packed cells for transfusion would be an appropriate intervention. The low hemoglobin level suggests that monitoring for possible need for transfusion is important, especially if there is internal bleeding or if the client’s condition deteriorates.
E. Administering antihypertensive medication is important in managing hypertension, which can contribute to the risk of aneurysm rupture. The patient’s elevated heart rate and blood pressure readings are concerning, and controlling blood pressure can help reduce stress on the aneurysm. Metoprolol, a beta-blocker, has been prescribed, which is appropriate for managing hypertension and reducing the risk of complications.
F. Insertion of an arterial line may be necessary for continuous monitoring of blood pressure, especially in critical situations or if surgery is imminent. It allows for precise measurement of blood pressure and frequent blood sampling.
G. While smoking cessation is important for long-term cardiovascular health and managing risk factors associated with aneurysms, it is less urgent in the immediate setting of acute care. Education on smoking cessation should be part of discharge planning and long-term management.
H. Educating the patient about the signs of an increasing aneurysm, such as worsening pain, changes in vital signs, or signs of rupture (e.g., severe abdominal or back pain, hypotension), is important for long- term management. However, in the acute phase, immediate interventions and monitoring are prioritized.