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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.Changing the dressing on the tracheostomy site is an important part of tracheostomy care, but it is not the first action that should be taken.
B.Suctioning the tracheostomy tube should only be performed if there are signs of airway obstruction (e.g., increased secretions, decreased oxygenation, or adventitious breath sounds). Suctioning too frequently or unnecessarily can cause mucosal damage and hypoxia.
C. Auscultating the lungs helps the nurse determine if there is increased secretions, diminished breath sounds, or other airway concerns that may require suctioning. This ensures that care is performed appropriately based on the client’s needs.
D.Cleaning the inner cannula is a necessary part of tracheostomy care, but it should bedone after assessing the airway and performing suctioning if needed.
Correct Answer is B
Explanation
Choice A rationale
Applying mystatin cream to the blistered areas is not typically recommended for herpes zoster lesions. Mystatin is an antifungal medication, and herpes zoster is caused by a virus, not a fungus.
Choice B rationale
Implementing contact precautions is recommended for patients with widespread herpes zoster lesions. This helps to prevent the spread of the virus to other people.
Choice C rationale
Using warm compresses on the crusted lesions is not typically recommended. While warm compresses can help with some skin conditions, they are not usually part of the care plan for herpes zoster.
Choice D rationale
Administering the shingles vaccine is not typically done once a patient already has widespread herpes zoster lesions. The vaccine is used to prevent shingles, not to treat active cases.
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