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 D
Explanation
A. "I should consume fish once per week": While consuming fish is beneficial, particularly fatty fish high in omega-3 fatty acids, this alone is not a comprehensive strategy for preventing hypertension.
B. "With a BMI of 30, I should focus on maintaining my current weight": With a BMI of 30, which is classified as obese, the focus should be on reducing weight rather than maintaining it to help prevent hypertension.
C. "I should exercise for 30 minutes three times per week": The recommended amount of exercise for cardiovascular health is at least 150 minutes of moderate-intensity exercise per week, which is more frequent than three times per week.
D. "I should consume no more than 2,000 milligrams of sodium per day": This is correct as reducing sodium intake to no more than 2,000 milligrams per day is a key strategy for preventing and managing hypertension.
Correct Answer is D
Explanation
A. Wear a simple face mask when caring for the client: This is incorrect because pertussis is highly contagious and requires more stringent precautions, such as an N95 mask, to prevent transmission.
B. Wear a gown when caring for the client: This is incorrect as wearing a gown is not typically required for pertussis unless there is a risk of direct contact with respiratory secretions.
C. Place the client in a negative air pressure room: This is incorrect because pertussis does not require negative air pressure; it is transmitted through droplets, not airborne particles.
D. Wear an N95 mask when in the client's room: This is correct because an N95 mask provides the necessary protection against respiratory droplets that can transmit pertussis, ensuring proper protection for healthcare workers.
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