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: 0.9% sodium chloride or normal saline is the only solution that should be administered with PRBCs, as it has an isotonic osmolarity and pH that are compatible with blood products and can prevent hemolysis or clotting.
Choice B reason: Dextrose 5% in water or D5W should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.
Choice C reason: Lactated Ringer's or LR should not be administered with PRBCs, as it contains calcium and lactate that can interfere with blood coagulation and cause clotting or embolism.
Choice D reason: Dextrose 5% in 0.45% sodium chloride or D5½NS should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.
Correct Answer is A
Explanation
Choice A reason: HbA1c or glycated hemoglobin is a measure of average blood glucose levels over the past 2 to 3 months. A lower HbA1c indicates better glycemic control and a lower risk of diabetes complications. The target HbA1c for most people with diabetes mellitus is less than 7%.
Choice B reason: HbA1c 12.5% is very high and indicates poor glycemic control and a high risk of diabetes complications, such as retinopathy, nephropathy, or neuropathy.
Choice C reason: Fasting blood glucose 100 mg/dL is within the normal range of 70 to 99 mg/dL and indicates normal glucose metabolism, but it does not reflect the long-term control of blood glucose levels over the past 3 months.
Choice D reason: Fasting blood glucose 70 mg/dL is at the lower end of the normal range and may indicate hypoglycemia or low blood glucose levels, which can cause symptoms such as sweating, trembling, hunger, or confusion.
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