Exhibits Nurse reviews updated chart data. For each intervention, click to indicate if it is indicated or contraindicated. Each row must have only one response option selected.

Rationale: Place client on 2 L/minute oxygen: The client's oxygen saturation is borderline at 94%, and with suspected aortic aneurysm and possible compromise, low-flow oxygen can help ensure adequate tissue oxygenation. This intervention is safe and aligns with the standing PRN order. Start 0.9% sodium chloride fluid bolus: Given the client’s low-normal blood pressure and risk for aneurysm rupture, fluid resuscitation may be needed to support perfusion. Carefully titrated fluids are appropriate to maintain hemodynamic stability while awaiting definitive surgical management. Ensure surgical consent has been completed: Time is critical in suspected abdominal aortic aneurysm (AAA) rupture. Preoperative preparation, including confirming surgical consent, should be done early in anticipation of emergent vascular intervention. Insert indwelling urinary catheter: This is contraindicated until the aneurysm is surgically managed or ruled out. Inserting a catheter increases intra-abdominal pressure and may worsen an unstable aneurysm. Additionally, unnecessary movement may elevate the risk of rupture in a fragile vessel. Document any skin lesions on lower legs: Peripheral vascular disease is often comorbid with aneurysms. Noting skin lesions helps establish a vascular baseline and may inform intraoperative risk or postoperative wound healing considerations. Mark pedal pulse sites with a single use marker: Pulse marking is essential preoperatively in vascular cases to monitor distal perfusion post-surgery. Marking now ensures pulses can be quickly located after potential surgical repair of the aneurysm.