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: This is incorrect. Vegetable shortening is high in saturated fat and trans fat, which can increase the risk of cardiovascular disease by raising the LDL (bad) cholesterol and lowering the HDL (good) cholesterol.
Choice B: This is incorrect. Lard is animal fat that is high in saturated fat and cholesterol, which can also increase the risk of cardiovascular disease by raising the LDL cholesterol and lowering the HDL cholesterol.
Choice C: This is correct. Canola oil is low in saturated fat and high in monounsaturated fat and omega-3 fatty acids, which can lower the risk of cardiovascular disease by lowering the LDL cholesterol and raising the HDL cholesterol.
Choice D: This is incorrect. Butter is dairy fat that is high in saturated fat and cholesterol, which can also increase the risk of cardiovascular disease by raising the LDL cholesterol and lowering the HDL cholesterol
Correct Answer is B
Explanation
Choice A reason: Restricting the client's calorie intake to no more than 2,000 calories per day is not an appropriate action, as it can impair wound healing and increase the risk of infection or malnutrition. The nurse should provide adequate calories and protein to meet the increased metabolic demands and support tissue repair and regeneration.
Choice B reason: Changing sterile gloves between caring for wounds on different areas of the body is an appropriate action, as it can prevent cross-contamination and infection of the burn wounds, which are susceptible to bacterial colonization and sepsis.
Choice C reason: Limiting movement or bending of the client's affected extremities is not an appropriate action, as it can cause contractures, joint stiffness, or muscle atrophy in the burned areas. The nurse should encourage early and frequent range of motion exercises and use splints or positioning devices to maintain functional alignment and mobility.
Choice D reason: Administering a diuretic if the client's urine output falls below 30 mL/hr is not an appropriate action, as it can worsen dehydration, electrolyte imbalance, or renal failure that can occur after severe burns. The nurse should monitor fluid status and urine output closely and administer intravenous fluids as prescribed to maintain adequate hydration and perfusion.
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