A nurse is collecting data from a client who is 8 hours postoperative following abdominal surgery. The client's blood pressure is 94/56 mm Hg. Which of the following actions should the nurse take first?

Increase the IV flow rate

Reassure the client

Compare the reading to the preoperative value

Cover the client with a warm blanket

Answer and Explanation

The Correct Answer is C

Choice A reason: Increasing the IV flow rate may be necessary if the blood pressure is significantly lower than the preoperative value and there are signs of hypovolemia.

Choice B reason: Reassuring the client is important, but it should not be the first action before assessing the clinical significance of the blood pressure reading.

Choice C reason: Comparing the current blood pressure with the preoperative value helps determine the next steps in management and whether the change is within expected limits.

Choice D reason: Covering the client with a warm blanket may be appropriate if the client is feeling cold, but it is not the first action to take in response to the blood pressure reading.

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Correct Answer is D

Explanation

Choice A reason: Keeping the client's bed in the low position is a safety measure to reduce the risk of injury from falls.

Choice B reason: Positioning the bedside table close to the client is helpful for ensuring that personal items are within reach and does not increase the risk of falls.

Choice C reason: Attaching the call light to the side rail of the client's bed ensures that the client can easily call for assistance and does not increase the risk of falls.

Choice D reason: Instructing the client to wear their own socks to the bathroom can be a risk factor for falls if the socks do not have nonslip grips, as they may cause the client to slip on the floor.

A. Restrict the client's calorie intake to no more than 2,000 calories per day. B. Change sterile gloves between caring for wounds on different areas of the body. C. Administer a diuretic if the client's urine output falls below 30 mL/hr. D. Limit movement or bending of the client's affected extremities.

Correct Answer is B

Explanation

Choice A reason: Caloric needs for a burn patient are typically higher due to the increased metabolic demand for healing, so restricting to 2,000 calories may not be sufficient.

Choice B reason: Changing gloves between wound care on different body parts is a standard infection control practice to prevent cross contamination.

Choice C reason: Administering a diuretic may be necessary if there is fluid overload, but it is not a routine action based solely on urine output unless specified by a physician.

Choice D reason: Limiting movement or bending of the affected extremities may be necessary initially, but movement is also important for recovery and should be encouraged as tolerated.

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