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 C
Explanation
A. "You will not become fatigued when you use assistive devices": This is incorrect as clients may still experience fatigue even with assistive devices, and energy conservation strategies should be discussed.
B. "Plan to hire a home care aide to perform all of your ADLs": This is not advisable as the goal is to encourage as much independence as possible; assistance should be provided based on need, not all tasks.
C. "Install grab bars in your shower to assist with your balance": This is correct as installing grab bars can enhance safety and support the client’s balance, helping to prevent falls and injuries.
D. "Place a towel in the shower to prevent slipping": This is not as effective as grab bars and may not provide adequate support or prevent slips as well as proper bathroom modifications.
Correct Answer is C
Explanation
A. "I will increase vitamin C intake by drinking orange juice": This is incorrect because citrus juices like orange juice can exacerbate GERD symptoms by increasing acid production.
B. "I will lie down for 30 minutes after each meal": This is incorrect as lying down after eating can increase the risk of acid reflux. Clients should remain upright for at least 2-3 hours after eating.
C. "I will eat six small meals each day": This is correct because eating smaller, more frequent meals can help reduce the frequency of GERD symptoms by decreasing stomach pressure and acid production.
D. "I will sleep flat on my back at night": This is incorrect as sleeping flat can worsen GERD symptoms. Elevating the head of the bed can help prevent acid reflux during sleep.
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