# A 65-year-old male is rushed to the emergency department with severe, tearing abdominal pain that radiates to his back. His blood pressure is 88/52 mmHg, heart rate is 118 bpm, and he appears pale and diaphoretic. The physician suspects an abdominal aortic aneurysm rupture. Based on this clinical presentation, which nursing action is the most immediate priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=177031  
> language: ko  
> subject: Adult Health

## 문제

A 65-year-old male is rushed to the emergency department with severe, tearing abdominal pain that radiates to his back. His blood pressure is 88/52 mmHg, heart rate is 118 bpm, and he appears pale and diaphoretic. The physician suspects an abdominal aortic aneurysm rupture. Based on this clinical presentation, which nursing action is the most immediate priority?

A 71-year-old male is rushed to the emergency department with severe, tearing abdominal pain that radiates to his back. His blood pressure is 88/52 mmHg, heart rate is 118 bpm, and he appears pale and diaphoretic. The physician suspects an abdominal aortic aneurysm rupture.

## 보기

1. Administer prescribed pain medication immediately
2. Obtain a complete set of vital signs every 15 minutes
3. Prepare the client for immediate CT scan
4. Establish large-bore IV access and monitor for signs of shock **✔ 정답**

**정답: 4**

## 해설

Establishing large-bore IV access is the priority to manage hemorrhagic shock in suspected AAA rupture, enabling fluid resuscitation and blood transfusion. Other options are secondary as they do not address the immediate life-threatening circulatory collapse.

## 심화 해설

Clinical Context and Pathophysiology

The patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe, tearing abdominal pain radiating to the back, hypotension (88/52 mmHg), and tachycardia (118 bpm). The pallor and diaphoresis are sympathetic nervous system responses to a catastrophic drop in circulating volume. A ruptured AAA leads to rapid arterial hemorrhage into the retroperitoneal space, causing profound hypovolemic shock. In this state, the primary physiological derangement is a critical loss of intravascular volume, which impairs oxygen delivery to vital organs [1]. The immediate threat to life is not pain, but circulatory collapse and end-organ hypoperfusion.

Analysis of Nursing Priorities

The nursing process in this emergency requires immediate prioritization based on the "ABC" (Airway, Breathing, Circulation) framework and the principles of shock management. While all listed options are important, they must be sequenced correctly.

- Option 1 (Administer prescribed pain medication immediately): Pain management is a valid concern, but administering opioid analgesics in a profoundly hypotensive patient can cause further vasodilation and cardiac depression, potentially precipitating cardiovascular arrest. Stabilizing circulation takes precedence.

- Option 2 (Obtain a complete set of vital signs every 15 minutes): Frequent monitoring is essential, but it is a secondary assessment action. The priority is an intervention that directly combats the life-threatening hypovolemia.

- Option 3 (Prepare the client for immediate CT scan): A CT angiogram is the definitive diagnostic tool for AAA. However, transporting an unstable patient in hypovolemic shock to the radiology department without first securing intravenous access and initiating resuscitation is dangerous and violates safe transport protocols.

- Option 4 (Establish large-bore IV access and monitor for signs of shock): This is the correct and most immediate priority. The foundation of managing hypovolemic shock is prompt fluid resuscitation, and the nurse's central role is establishing the means to deliver it [1]. Large-bore IV access (e.g., 14- or 16-gauge) allows for rapid infusion of crystalloids and blood products to restore intravascular volume and improve oxygen delivery. The evidence emphasizes that a thorough understanding of physiology must guide management to address hemodynamic derangements, rather than rigidly following protocols . In this case, the physiological understanding is that the patient's preload-dependent state requires immediate volume restoration. Monitoring for shock signs is a continuous, concurrent nursing responsibility that begins at the first patient contact.

Evidence-Based Rationale for the Priority

The best evidence for managing hypovolemic shock in emergency care highlights that prompt fluid resuscitation is critical, with nurses playing a central role in early recognition and timely intervention [1]. The initial, most critical intervention a nurse can perform is to establish reliable vascular access to begin replacing the lost intravascular volume. This directly addresses the pathophysiology of the condition, where significant blood loss impairs oxygen delivery to vital organs [1]. The case report further supports that management must be guided by a clear understanding of the underlying physiology to appropriately address hemodynamic instability, cautioning that protocol-driven care without clinical judgment can be detrimental . In a suspected AAA rupture, the clinical judgment is clear: the patient is exsanguinating, and the nurse's immediate action of securing large-bore IV access is the essential first step that enables all subsequent life-saving therapies, including fluid resuscitation and surgical intervention.References (research sources)

- [1]Best evidence for fluid resuscitation nursing in hypovolemic shock patients in emergency care based on GRADE system.Research articleWang Y, Lin J, Lin Y. (2026) · DOI: 10.2478/abm-2026-0009

## 임상 시나리오

Ruptured AAA: Immediate Nursing PriorityPrioritizing Circulation in Hemorrhagic Shock
The primary goal for a suspected ruptured abdominal aortic aneurysm (AAA) with hypotension is to restore circulating volume. The immediate nursing action is to establish large-bore IV access (e.g., 14-18 gauge) in both antecubital fossae.

Initiate rapid infusion of warmed crystalloids (e.g., Lactated Ringer's or Normal Saline) as prescribed to maintain a permissive hypotension strategy, targeting a systolic BP of 80-100 mmHg to avoid dislodging an early clot while ensuring end-organ perfusion.

CautionAvoid administering opioid analgesics before stabilizing blood pressure, as they can cause vasodilation and myocardial depression, precipitating complete cardiovascular collapse. Frequent vital signs and diagnostic scans are secondary to volume resuscitation.

## 핵심 개념

- **Abdominal Aortic Aneurysm (AAA) Rupture** — A life-threatening condition where a weakened area of the abdominal aorta bursts, leading to rapid internal hemorrhage and hypovolemic shock.
- **Hypovolemic Shock** — A state of inadequate tissue perfusion caused by a critical loss of intravascular fluid volume, characterized by hypotension, tachycardia, and altered mental status.
- **ABC Framework** — A prioritization mnemonic in emergency care: Airway, Breathing, Circulation. Life-threatening circulatory problems are addressed immediately after airway and breathing.
- **Large-Bore IV Access** — Insertion of a short, wide-diameter intravenous catheter (e.g., 14-18 gauge) to allow rapid infusion of large volumes of fluid or blood products.

## 같은 주제 문제

- [A nurse is assessing a 70-year-old male client with a known 5.2 cm abdominal aortic aneury…](https://mymerci.kr/pages/nclex_q.php?qn_id=177029)
- [A nurse is assessing a 72-year-old female client who presents to the emergency department …](https://mymerci.kr/pages/nclex_q.php?qn_id=177030)
- [A 54-year-old male client presents to the emergency department with severe abdominal pain …](https://mymerci.kr/pages/nclex_q.php?qn_id=177033)
- [A nurse is caring for a client with a thoracic aortic aneurysm who is scheduled for surgic…](https://mymerci.kr/pages/nclex_q.php?qn_id=177034)
- [The nurse is evaluating a client and determines that which of these findings requires the …](https://mymerci.kr/pages/nclex_q.php?qn_id=177036)
- [A nurse is caring for a 45-year-old female client with suspected thoracic aortic aneurysm …](https://mymerci.kr/pages/nclex_q.php?qn_id=177037)
- [Which of the following findings is the most critical for the nurse to report to the health…](https://mymerci.kr/pages/nclex_q.php?qn_id=177038)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._