A nurse is caring for a patient who has just returned from the operating room after a major abdominal surgery. The nurse notices that the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, oxygen saturation is 92%, and urine output is 20 mL/h. What is the nurse's priority action?

Administer oxygen via nasal cannula.

Increase the rate of intravenous fluids.

Notify the physician or surgeon.

Administer pain medication.

Answer and Explanation

The Correct Answer is B

A. Administering oxygen may help improve oxygen saturation, but the primary concern is hypotension and tachycardia, which suggest possible hypovolemia.
B. The patient’s vital signs, BP 90/60 mmHg, pulse 120 beats/min, urine output 20 mL/h, indicate early hypovolemic shock. The priority intervention is to increase intravenous fluids to restore circulating volume and perfusion.
C. Notifying the physician is important but should follow initiating immediate interventions to stabilize the patient.
D. Administering pain medication does not address the patient’s hemodynamic instability and is not a priority at this time.

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Correct Answer is B

Explanation

A. "I will give you some medication to help with your pain.” B. "Can you describe how your pain affects your daily activities?” C. "How long have you had this pain and what makes it better or worse?” D. "That sounds very painful, I'm sorry you are going through this."

Correct Answer is B

Explanation

Choice A reason:

This is not the best response because it does not address the patient's pain experience or offer any empathy. It also implies that medication is the only option for pain relief, which may not be true.

Choice B reason:

This is the best response because it acknowledges the patient's pain and asks them to elaborate on how it affects their daily activities. This can help the nurse assess the impact of pain on the patient's quality of life and plan appropriate interventions.

Choice C reason:

This is not the best response because it focuses on the duration and triggers of pain, which are more relevant for chronic pain than acute pain. It also does not show empathy or validate the patient's pain rating.

Choice D reason:

This is not the best response because it only expresses sympathy but does not ask the patient any questions or offer any solutions. It may also sound patronizing or dismissive to some patients.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a patient's pain level after surgery. The patient rates their pain as 8 out of 10 and says it feels like a sharp stabbing pain in the surgical site. What should the nurse say to the patient?

Correct Answer is B

Explanation

A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?

A nurse is changing the dressing of a patient who had a chest surgery two days ago. The nurse observes that the wound edges are separated and there is a small amount of pink serous drainage on the dressing. What should the nurse do?

A nurse is teaching a patient about wound care after a minor surgical procedure. Which of the following instructions should the nurse include? (Select all that apply.)

A nurse is monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?

A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)

A nurse is assessing a client who had a thyroidectomy. The nurse suspects that the client is experiencing hypocalcemia due to inadvertent damage to the parathyroid glands. Which of the following statements by the client supports this suspicion?

A nurse is preparing a client for discharge after a mastectomy. The nurse teaches the client how to perform arm exercises to prevent lymphedema and promote mobility. Which of the following statements by the client indicates an understanding of the teaching?