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 D

Explanation

Choice A reason: Hematuria is expected after lithotripsy and should be monitored, but it is not the most critical instruction.

Choice B reason: Using an incentive spirometer is important for respiratory care but not specific to lithotripsy.

Choice C reason: Restricting physical activities is not necessary unless advised by the healthcare provider.

Choice D reason:

The correct answer is d) because monitoring the urinary stream for a decrease in output is crucial to detect any complications such as obstruction or infection after lithotripsy.

A. Breathe deeply, followed by coughing up the sputum. B. Restrict fluids before expectorating the sputum specimen. C. Obtain the specimen before bedtime. D. Avoid mouth care prior to collecting the sputum.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because taking deep breaths followed by coughing helps produce a sputum sample from the lungs, which is necessary for accurate diagnostic testing.

Choice B reason: Restricting fluids before expectorating the sputum specimen is not necessary and may make it more difficult to produce a sample.

Choice C reason: Sputum specimens are best collected in the morning when secretions have accumulated overnight.

Choice D reason: Mouth care should be performed prior to sputum collection to reduce contamination from oral bacteria.

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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 with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

Correct Answer is D

Explanation

The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum sample?

Correct Answer is A

Explanation

Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

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