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
Choice A reason: Doing testicular self-exam every 6 months without fail is not an adequate frequency, as it can delay the detection of any changes or abnormalities in the testes that may indicate cancer or other conditions. Men should perform testicular self-exam monthly, preferably after a warm bath or shower.
Choice B reason: The flu shot received last year will not last for 2 years, as it only provides protection against specific strains of influenza virus that may change from year to year. People should get a flu shot annually, preferably before the flu season starts.
Choice C reason: Examining breasts a week after each menstrual period is an optimal time, as breasts are less likely to be swollen, tender, or lumpy due to hormonal fluctuations. Women should perform breast self-exam monthly, preferably at the same time each month.
Choice D reason: Getting a hepatitis B vaccine on a yearly basis is not necessary, as it only requires three doses at 0, 1, and 6 months to provide lifelong immunity against hepatitis B virus infection. People who are at high risk of exposure to hepatitis B virus should get tested for antibodies before receiving the vaccine series.
Correct Answer is B
Explanation
Choice A reason: Blurred vision is not an expected side effect of digoxin, but a sign of digoxin toxicity, which requires immediate medical attention.
Choice B reason: This is the correct answer because digoxin can cause hypokalemia (low potassium levels), which increases the risk of digoxin toxicity. Therefore, clients taking digoxin need to have their potassium levels monitored regularly and consume foods rich in potassium.
Choice C reason: Antacids can interfere with the absorption of digoxin and reduce its effectiveness. Clients taking digoxin should avoid taking antacids within two hours of taking the medication.
Choice D reason: Weighing oneself every other day is not related to digoxin therapy, but to fluid balance. Clients with heart failure, who are often prescribed digoxin, need to monitor their weight daily and report any significant changes to their health care provider.
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