A nurse is collecting data from a client who is 8 hr 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.
Cover the client with a warm blanket.
Compare the reading to the preoperative value.
Reassure the client.
The Correct Answer is A
A. Increase the IV flow rate: This is correct as the client's blood pressure is low, which could indicate hypovolemia or shock. Increasing the IV flow rate can help improve blood volume and blood pressure.
B. Cover the client with a warm blanket: While this can help with hypothermia, it does not address the immediate concern of low blood pressure.
C. Compare the reading to the preoperative value: Comparing to the preoperative value can provide context but does not directly address the current low blood pressure.
D. Reassure the client: Reassuring the client is important but not the first priority. Addressing the physiological issue of low blood pressure should be the initial focus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
• Desired dose: 15,000 units
• Available concentration: 10,000 units/mL
• To find the volume to administer, we can use the formula:
• Volume to administer (mL) = Desired dose (units) / Concentration (units/mL)
• Volume to administer = 15,000 units / 10,000 units/mL = 1.5 mL
Correct Answer is B
Explanation
A. Discourage drinking with a straw: Drinking with a straw is not typically discouraged for stomatitis and may actually help the client avoid contact with painful areas in the mouth.
B. Recommend consumption of cold items: This is correct as cold items can provide soothing relief for the inflamed mucous membranes in stomatitis, helping to reduce discomfort.
C. Provide an alcohol-based mouthwash: Alcohol-based mouthwashes can irritate the mucous membranes further and should be avoided. Non-alcoholic, soothing mouthwashes or saline rinses are preferred.
D. Minimize the use of gravies and sauces: While gravies and sauces can be irritating due to their acidity or spiciness, the primary recommendation is to focus on soothing and non-irritating foods and oral care practices.
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