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 C
Explanation
The correct answer is C. Consume a diet high in antioxidants.
Choice A: Complete breast self-examinations one week prior to menstruation.
Performing breast self-examinations one week prior to menstruation is not recommended. The best time to perform a breast self-exam is about 3 to 5 days after your period starts, when your breasts are least likely to be tender or swollen. This timing helps in detecting any unusual changes more accurately.
Choice B: Expect clear discharge from the nipples.
While some nipple discharge can be normal, it is not something that should be expected as a routine part of breast health. Clear, yellow, or white discharge can occur due to hormonal changes, but any spontaneous discharge, especially if it is bloody or from one breast, should be evaluated by a healthcare provider.
Choice C: Consume a diet high in antioxidants.
Consuming a diet high in antioxidants is beneficial for overall health and may help reduce the risk of various diseases, including cancer. Antioxidants help neutralize free radicals, which can damage cells and contribute to cancer development. Foods rich in antioxidants include fruits, vegetables, nuts, and whole grains.
Choice D: Include meats grilled over high heat in the diet.
Including meats grilled over high heat in the diet is not advisable for someone concerned about cancer risk. Grilling meats at high temperatures can produce carcinogens such as heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs), which have been linked to an increased risk of cancer. Therefore, it is better to avoid or limit the consumption of grilled meats.
Correct Answer is D
Explanation
Choice A: This is incorrect because weight loss is not the highest priority finding for the nurse to report to the provider. Weight loss can be a common symptom of leukemia due to decreased appetite, increased metabolism, or malabsorption.
Choice B: This is incorrect because fatigue is not the highest priority finding for the nurse to report to the provider. Fatigue can be a common symptom of leukemia due to anemia, infection, or poor nutrition.
Choice C: This is incorrect because dysuria is not the highest priority finding for the nurse to report to the provider. Dysuria can indicate a urinary tract infection, which can be treated with antibiotics and fluids.
Choice D: This is correct because elevated temperature is the highest priority finding for the nurse to report to the provider. Elevated temperature can indicate a serious infection, which can be life-threatening for a client who has leukemia and a compromised immune system.
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