A nurse is assessing a patient who is 8 hours postoperative following abdominal surgery. The patient’s blood pressure is 94/56 mm Hg. What should the nurse do first?
Compare the reading to the preoperative value.
Cover the patient with a warm blanket.
Increase the IV flow rate.
Reassure the patient.
The Correct Answer is A
Comparing the current blood pressure reading to the preoperative value is the first step the nurse should take. This will help determine if the patient’s blood pressure has significantly dropped, which could indicate hypovolemia or shock.
Choice B rationale
Covering the patient with a warm blanket may be helpful if the patient is feeling cold or showing signs of hypothermia, but it would not address the underlying cause of the low blood pressure.
Choice C rationale
Increasing the IV flow rate might be necessary if the patient is hypovolemic, but this decision should be based on additional assessment data and physician orders.
Choice D rationale
Reassuring the patient is important, but it should not be the first action. The nurse needs to assess and address the cause of the low blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Obtaining an x-ray of the growth plate every 6 months is not a standard recommendation for preventing osteoporosis. Growth plates are only present in children and adolescents, and they close once a person reaches their full adult height.
Choice B rationale
Engaging in passive range-of-motion exercises is not typically recommended for preventing osteoporosis. Weight-bearing and resistance exercises are more beneficial for bone health.
Choice C rationale
Decreasing vitamin K in the diet is not recommended for preventing osteoporosis. Vitamin K is necessary for bone health, and a deficiency can actually increase the risk of osteoporosis.
Choice D rationale
Consuming vitamin D supplements daily is often recommended for preventing osteoporosis. Vitamin D is necessary for the body to absorb calcium, which is essential for bone health.
Correct Answer is A
Explanation
Choice A rationale
When a patient is initiating IV therapy, one of the tasks a nurse may perform is administering IV fluids with a potassium supplement. This is a common task in IV therapy. Therefore, this choice is correct.
Choice B rationale
Administering pain medication could be a part of a nurse’s responsibilities, but it is not specific to the initiation of IV therapy. Therefore, this choice is incorrect.
Choice C rationale
Inserting a nasogastric tube is not a task associated with initiating IV therapy. Therefore, this choice is incorrect.
Choice D rationale
Requesting a prescription for an antiemetic is not a task associated with initiating IV therapy. Therefore, this choice is incorrect.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.