One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Increase frequency of BP assessments.

Encourage the client to breathe deeply.

Check the abdominal surgical dressing.

Review the client's baseline BP trends.

Answer and Explanation

The Correct Answer is C

Choice A reason: Increasing the frequency of BP assessments is important to monitor the client's condition, but it does not address the potential cause of the drop in blood pressure.

Choice B reason: Encouraging the client to breathe deeply is useful for overall respiratory function but does not address the specific issue of the dropping blood pressure.

Choice C reason:

The correct answer is c) because checking the abdominal surgical dressing can help identify if there is postoperative bleeding or other complications at the surgical site, which could be causing the drop in blood pressure.

Choice D reason: Reviewing the client's baseline BP trends provides useful information but does not address the immediate potential cause of the blood pressure change.

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Correct Answer is B

Explanation

Choice A reason: Arthritic joint changes and chronic pain are not related to an ABO incompatibility reaction.

Choice B reason:

The correct answer is b) because lower back pain and hypotension are signs of a hemolytic transfusion reaction, which requires immediate intervention.

Choice C reason: Acute rhinitis and nasal stuffiness are not related to an ABO incompatibility reaction.

Choice D reason: Delayed painful rash with urticaria can indicate an allergic reaction but is not specific to a hemolytic transfusion reaction.

A. Avoid driving a car for 2 weeks. B. Drink 3 liters of water each day. C. Eliminate all spicy foods from your diet. D. Clamp the catheter when taking a shower.

Correct Answer is B

Explanation

Choice A reason: Avoiding driving is important but not the most critical instruction.

Choice B reason:

The correct answer is b) because drinking plenty of water helps flush the bladder, reduce the risk of infection, and prevent blood clots.

Choice C reason: Eliminating spicy foods may help with overall comfort but is not as important as maintaining proper hydration.

Choice D reason: Clamping the catheter during a shower is not necessary and could cause complications.

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One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Correct Answer is B

Explanation

Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

Correct Answer is B

Explanation

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