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 C

Explanation

Choice A reason: While the chest x-ray report is important, it is not as immediately critical as a low potassium level.

Choice B reason: The surgical consent form is important but can be addressed quickly before surgery.

Choice C reason:

The correct answer is c) because a preoperative serum potassium level of 2.8 mEq/L is dangerously low and requires immediate correction to avoid cardiac complications during surgery.

Choice D reason: A pulse oximeter reading of 96% is within normal limits and does not require immediate action.

A. A 70-year-old fair-skinned client who works as a secretary. B. A 65-year-old fair-skinned client who is a construction worker. C. A 25-year-old dark-skinned client whose mother had skin cancer. D. A 16-year-old dark-skinned client who tans in tanning beds once a week.

Correct Answer is B

Explanation

Choice A reason: While being fair-skinned and older increases risk, exposure to UV radiation is a significant factor.

Choice B reason:

The correct answer is b) because a fair-skinned client who works outdoors (construction worker) has higher exposure to UV radiation, increasing the risk of skin cancer.

Choice C reason: Having a family history of skin cancer is a risk factor, but dark-skinned individuals have lower risk compared to fair-skinned individuals with high UV exposure.

Choice D reason: Tanning bed use increases risk, but fair-skinned individuals with prolonged UV exposure have a higher overall risk.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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