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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While pulling the fire alarm is important, the immediate priority is the safety of the client.
Choice B reason: The nurse's first action should be to remove the client from the room to ensure their safety from the potential fire.
Choice C reason: Closing the door may help contain smoke and fire, but it is not the first action to take before ensuring the client's safety.
Choice D reason: Obtaining a fire extinguisher is important after the client is safe and the alarm has been pulled to alert others.
Correct Answer is D
Explanation
Choice A reason: Liquid iron supplements should not be taken undiluted as they can stain the teeth and may cause irritation to the digestive tract.
Choice B reason: Taking iron supplements with antacids is not recommended as antacids can interfere with the absorption of iron.
Choice C reason: Black stools can be a normal side effect of iron supplementation due to the unabsorbed iron; it does not necessarily indicate a need to contact a doctor unless there are other symptoms of concern.
Choice D reason: Increasing fiber intake can help prevent constipation, which is a common side effect of iron supplements.
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