A nurse is collecting data from a client who is 4 hr postoperative following abdominal surgery. The client's blood pressure is 90/60 mm Hg. Which of the following actions should the nurse take first?
Cover the client with a warm blanket.
Increase the IV fluid rate.
Reassure the client.
Compare the reading to the preoperative value.
The Correct Answer is D
Choice D: Comparing the reading to the preoperative value is the first action that the nurse should take because it can help determine if the client's blood pressure is normal for them or if it indicates hypotension, which can be a sign of hemorrhage, shock, or infection.
Choice a is not correct because covering the client with a warm blanket is not the first action that the nurse should take, but rather an intervention that can help prevent hypothermia and shivering, which can increase oxygen demand and blood loss.
Choice b is not correct because increasing the IV fluid rate is not the first action that the nurse should take, but rather an intervention that can help restore fluid volume and blood pressure, if indicated by other data and prescribed by the provider.
Choice c is not correct because reassuring the client is not the first action that the nurse should take, but rather an intervention that can help reduce anxiety and stress, which can affect blood pressure and heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Purchasing a stoma cap that can cover and conceal the ileostomy when not in use indicates that the client is in the acceptance stage of grieving, as it shows that they have adapted to their new condition and are able to resume their normal activities and social interactions.
Choice B reason: Having their partner empty their pouch for them every morning indicates that the client is in the denial stage of grieving, as it shows that they are avoiding or rejecting their new condition and are dependent on others for their care.
Choice C reason: Being embarrassed by the odor that comes from their ileostomy indicates that the client is in the depression stage of grieving, as it shows that they have low self-esteem and negative feelings about their new condition and its impact on their quality of life.
Choice D reason: Missing going to their church meetings because of their ostomy indicates that the client is in the anger stage of grieving, as it shows that they have resentment and frustration about their new condition and its interference with their previous routines and values.
Correct Answer is A
Explanation
Choice A reason: Difficulty swallowing is a sign of anaphylaxis, which is a severe allergic reaction that can cause swelling of the throat and tongue, leading to airway obstruction and respiratory distress.
Choice B reason: Petechial rash on the abdomen is not a sign of anaphylaxis, but rather a sign of thrombocytopenia, which is a low platelet count that can cause bleeding under the skin.
Choice C reason: Hypertension is not a sign of anaphylaxis, but rather a sign of high blood pressure, which can be caused by various factors such as stress, pain, or kidney disease.
Choice D reason: Bilateral tinnitus is not a sign of anaphylaxis, but rather a sign of hearing loss or damage, which can be caused by exposure to loud noise, ear infection, or medication side effects.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.