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. Perform immediate defibrillation: This is necessary for ventricular tachycardia with a pulse if it is unstable, but first, assess the client’s condition.
B. Provide pulmonary ventilation: This may be required depending on the client's breathing status but is secondary to assessing the pulse.
C. Determine palpable pulse: This is the priority action. Determining whether the client has a pulse helps guide the next steps—if the client has a pulse but is symptomatic, treatment will differ from if the client is pulseless.
D. Begin chest compressions: This is done if the client is pulseless. If there is a pulse, other interventions are needed first.
Correct Answer is A
Explanation
A. Participate in reminiscence therapy with the client: This is correct as reminiscence therapy, which involves discussing past experiences and memories, can help improve mood and cognitive function in clients with Alzheimer's disease.
B. Alternate the client's daily routine: Consistency is important for clients with Alzheimer's disease to reduce confusion and anxiety. Alternating the routine can be disorienting.
C. Keep the lights dimmed: Keeping the lights dimmed can contribute to confusion and disorientation. Adequate lighting is essential for safety and to help the client maintain a clear sense of time and space.
D. Raise the four side rails on the client's bed: Raising all four side rails can be considered a form of restraint and is not recommended. It can increase the risk of injury and does not address the client's needs appropriately.
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