The nurse is caring for a client with abdominal aortic aneurysm. Which observation by the nurse indicates the need for immediate intervention?

  • complaints of yellow-tinted vision
  • sudden onset of frothy, pink sputum
  • urinary output of 75 mL/hr. per urinary catheter
  • complaints of sudden and severe back pain and shortness of breath
Number 4 is correct.
Sudden back pain and shortness of breath indicate rupture of the aneurysm, which is an emergency. The nurse should notify the health care provider, monitor neurological and vital signs, and remain with the client. Yellow-tinted vision is a finding of digitalis toxicity. Frothy, pink sputum is a sign of pulmonary edema. Urinary output of 75 mL/hr. is a normal urinary output.