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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Orthopneic: This position is used for clients with respiratory distress and is not suitable for sigmoidoscopy.
B. Knee-chest: This is correct as the knee-chest position is commonly used for sigmoidoscopy to provide optimal access to the rectum and sigmoid colon.
C. Trendelenburg: This position, with the head lower than the feet, is typically used for shock or hypotension, not for sigmoidoscopy.
D. Prone: The prone position is not appropriate for sigmoidoscopy as it does not allow adequate access to the rectum and sigmoid colon.

A. Wear a simple face mask when caring for the client. B. Wear a gown when caring for the client. C. Place the client in a negative air pressure room. D. Wear an N95 mask when in the client's room.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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