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
Unscrewing the pins to clean the pin sites is not recommended. This could lead to infection and disrupt the traction.
Choice B rationale
Loosening the rope knots holding the weights for 30 minutes if the patient reports pain is not recommended. The weights provide the necessary force to align and immobilize the body part and should not be removed.
Choice C rationale
Ensuring that at least 4.5 kg (10 lb) of weight is applied to the patient’s traction is a correct action. The amount of weight applied must be sufficient to provide the necessary force for alignment.
Choice D rationale
Removing the weights while turning the patient in bed is not recommended. The weights must remain in place to maintain the therapeutic effect of the traction.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should clarify the prescription for Furosemide due to the client’s 2. Potassium level. The client’s potassium level is 3.2 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. This could indicate hypokalemia, a condition that can cause weakness, fatigue, and heart rhythm problems. Therefore, it would be important for the nurse to clarify the prescription for potassium chloride, which is a medication used to treat or prevent low potassium levels. Please note that this is an assessment based on the information provided
Furosemide, also known as a loop diuretic, works by inhibiting the Na+/K+/2Cl- cotransporter in the ascending thick loop of Henle in the kidneys1. This part of the kidney is responsible for reabsorbing sodium, chloride, and potassium from the urine back into the body1.
When Furosemide inhibits this process, it leads to an increase in the amount of these electrolytes in the urine, which in turn leads to their decreased levels in the body1. This is why Furosemide can cause a decrease in potassium levels in the body, a condition known as hypokalemia23.
It’s important to note that while Furosemide helps in relieving the body of excess fluid, its use may lead to the depletion of certain electrolytes in the body, such as potassium3. Therefore, if you are taking Furosemide, your doctor may need to monitor your potassium levels or have you consume more potassium4.
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