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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Intermittent abdominal pain: While abdominal pain may occur, it is not specifically related to total parenteral nutrition (TPN) and burn care.
B. Decreased calcium levels: Decreased calcium levels are not the primary concern with TPN. Calcium levels should be monitored, but other issues are more directly related to TPN.
C. Increased serum glucose levels: This is correct as TPN often contains high levels of glucose, which can lead to hyperglycemia. Monitoring serum glucose levels is crucial in managing TPN to avoid complications.
D. Absent bowel sounds: Bowel sounds are not directly affected by TPN. However, monitoring for gastrointestinal function is important in the overall assessment of the client.
Correct Answer is C
Explanation
A. Warm the insulin vial to dissolve any crystals that develop: Insulin should not be warmed as this can alter its efficacy. If crystals are present, the vial should be gently rolled, not heated.
B. Keep unopened insulin vials in the freezer: Insulin should not be kept in the freezer. Unopened vials should be stored in the refrigerator.
C. Store opened insulin vials at room temperature for up to 4 weeks: Opened insulin vials can be stored at room temperature for up to 4 weeks, which helps maintain its stability and usability.
D. Plan to eat a snack 6 hr after insulin administration: The timing of snacks should be aligned with insulin administration based on the type and dosage, not a fixed interval of 6 hours.
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