The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Ensure the IV solution is infusing at the prescribed rate.

Listen to lung sounds.

Notify the healthcare provider of the findings.

Check under the back for evidence of bleeding.

Answer and Explanation

The Correct Answer is D

A.   Ensuring that the IV solution is infusing at the prescribed rate is an important task to maintain adequate fluid and electrolyte balance, especially if the client is experiencing signs of shock or low blood pressure. However, this action alone does not address the immediate need to assess or intervene for potential critical issues such as bleeding or severe hemodynamic instability.
B.   Listening to lung sounds can help assess for pulmonary complications, such as fluid accumulation or atelectasis, which can be relevant postoperatively. However, in the context of hypotension, tachycardia, and altered mental status, the priority is to address potential critical issues related to circulatory stability and bleeding.
C.   It is essential to inform the healthcare provider of the client's condition, but this should be done after initial interventions to stabilize the client. This action is necessary but not the first priority.
D.   The first action should be to check for any signs of bleeding, especially after abdominal surgery where internal bleeding is a possibility.

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Correct Answer is C

Explanation

A. An indwelling urinary catheter is generally used for monitoring urine output in patients with urinary issues or those who are unable to void. It is not the first-line intervention for a client with symptoms suggesting a possible bowel obstruction or gastrointestinal complication. While monitoring urine output may be important, it does not address the immediate concern of the client’s gastrointestinal symptoms.
B. An abdominal x-ray can help diagnose conditions such as bowel obstruction, ileus, or other abdominal issues by visualizing the presence of air-fluid levels or distended bowel loops. While this diagnostic step is important, it should follow interventions that might provide immediate symptomatic relief or help manage the suspected condition.
C. Inserting an NGT and attaching it to low intermittent suction is a critical intervention for managing symptoms of bowel obstruction or severe gastrointestinal distress. The dark brown, foul-smelling vomit and hyperactive bowel sounds suggest that the client might have a bowel obstruction or significant gastrointestinal complication. An NGT can help decompress the stomach, relieve pressure, reduce vomiting, and prevent further gastrointestinal complications.
D. While providing analgesics for pain and fever is important for overall symptom management, it does not address the immediate cause of the client’s symptoms. The focus should be on diagnosing and managing the underlying issue causing the symptoms, such as a bowel obstruction, rather than just treating pain or fever.

A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction). B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L). C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L). D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);

Correct Answer is C

Explanation

A. This would indicate fluid volume deficit, not improvement. Increasing IV fluids should lead to a decrease in hematocrit, not an increase.
B. This is not a desired outcome for a patient with pancreatitis, as hyperglycemia is a common complication. The focus should be on maintaining stable blood glucose levels.
C. BUN is a marker of kidney function and hydration status. A decrease in BUN indicates improved renal perfusion, which is a therapeutic outcome of increasing IV fluids.
D. While a decrease in amylase is generally a good sign for pancreatitis, it is not a direct result of increasing IV fluids. Amylase levels decrease as the pancreatitis improves.

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The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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