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 C
Explanation
Choice A rationale
Keeping unopened insulin vials in the freezer is not recommended. Freezing can disrupt the insulin molecule and affect its efficacy.
Choice B rationale
Planning to eat a snack 6 hours after insulin administration is not a standard recommendation. The timing of meals and snacks should be individualized based on the type of insulin, blood glucose levels, and lifestyle.
Choice C rationale
Storing opened insulin vials at room temperature for up to 4 weeks is a correct practice. Insulin stored at room temperature causes less discomfort on injection than cold insulin.
Choice D rationale
Warming the insulin vial to dissolve any crystals that develop is not a standard practice. Insulin should not be used if it appears cloudy or discolored.
Correct Answer is A
Explanation
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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