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 A
Explanation
Choice A rationale
Without specific patient data, it’s challenging to provide a detailed rationale.
However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.
Choice B rationale
Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.
Choice C rationale
Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.
Choice D rationale
Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"A,B"},"F":{"answers":"A,B"},"G":{"answers":"A"},"H":{"answers":"A,B"},"I":{"answers":"A,B"},"J":{"answers":"A,B"}}
Explanation
- Abdominal Pain: Common in both small bowel obstruction and acute pancreatitis.
- No Bowel Movement for 5 days: More indicative of small bowel obstruction.
- Vomiting: Can occur in both conditions.
- Abdominal Distention: Seen in both small bowel obstruction and acute pancreatitis.
- Increased Heart Rate: Can be a response to pain or infection in both conditions.
- Elevated Temperature: Can occur in both conditions due to inflammation or infection.
- Distention with fluid and gas in the small bowel (CT Scan): Specific to small bowel obstruction.
- Sodium: 130 mEq/L: Hyponatremia can be seen in both conditions.
- Potassium: 3.3 mEq/L: Hypokalemia can be seen in both conditions.
- WBC count: 10,000/mm: Leukocytosis can be seen in both conditions due to inflammation.
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