Question 29Type: MCMAThe nurse suspects that a patient who is recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. Which findings are indications of this event? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Urine output 45 mL/hr2. Complaint of groin pain3. Abdominal dressing dry and intact4. Respiratory rate 16 and regular5. Complaint of back discomfortCorrect Answer: 2,5Rationale 1: The nurse would not be concerned about urine output unless it was less than 30mL/hour.Rationale 2: The nurse should monitor for and report any manifestations of graft leakage, including groin pain.Rationale 3: This is a normal finding.Rationale 4: This is a normal finding.Rationale 5: The nurse should monitor for and report any manifestations of graft leakage, including back pain.
Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 35-3Question 30Type: MCMA