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
Participating in reminiscence therapy can be beneficial for patients with Alzheimer’s disease. This therapy involves discussing past experiences and life events, which can help improve mood, enhance communication, and maintain self-identity.
Choice B rationale
Raising all four side rails on a patient’s bed is not recommended. This can be considered a form of restraint and can increase the risk of injury if the patient attempts to climb over the rails. It’s important to promote a safe environment while respecting the patient’s rights.
Choice C rationale
Alternating the patient’s daily routine can be confusing and disorienting for individuals with Alzheimer’s disease. Maintaining a consistent routine can provide a sense of security and predictability.
Choice D rationale
Keeping the lights dimmed is not specifically beneficial for patients with Alzheimer’s disease. Adequate lighting can help prevent falls and other accidents. However, creating a calm and quiet environment can help reduce agitation.
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Scheduled times for dressing changes are not typically included in transfer documentation. This information is usually part of the patient’s daily care plan and can be communicated to the receiving unit as needed.
Choice B rationale
The primary health problem is crucial information to include in the transfer documentation. It provides the receiving unit with a clear understanding of the patient’s main health issue and the reason for their transfer.
Choice C rationale
Admission vital signs from 1 week ago are not typically included in transfer documentation. The most recent vital signs are more relevant and provide a better indication of the patient’s current health status.
Choice D rationale
Current medication prescriptions are essential to include in the transfer documentation. This information ensures continuity of care and prevents medication errors.
Choice E rationale
The number of family members who have visited is not typically included in transfer documentation. This information is not directly related to the patient’s health status or care needs.
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