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","D","E"]
Explanation
Choice A reason: Aspirin is an antiplatelet agent and may not be recommended immediately postprostatectomy due to the risk of bleeding.
Choice B reason: Patients should avoid lifting heavy objects postprostatectomy to prevent strain on the surgical site.
Choice C reason: Resuming sexual intercourse should be discussed with the healthcare provider, as it typically requires a longer recovery period.
Choice D reason: Showering is recommended over taking a tub bath to prevent infection at the surgical site.
Choice E reason: Observing blood in the urine after coughing may occur as the surgical area heals, but it should be monitored for any signs of complications.
Correct Answer is D
Explanation
Choice A reason: Obtaining vital signs is important, but it is not the first action to take when a client is experiencing dyspnea.
Choice B reason: Administering heparin is a treatment for pulmonary embolism, but the immediate need is to address the client's breathing difficulty.
Choice C reason: Encouraging the client to cough and deep breathe may be helpful, but it is not the first action to take for acute dyspnea.
Choice D reason: Placing the client in high Fowler’s position can help improve breathing and oxygenation, which is the immediate priority for a client experiencing dyspnea.
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