A nurse is collecting data from a client who is 4 hr postoperative following abdominal surgery. The client's blood pressure is 90/60 mm Hg. Which of the following actions should the nurse take first?
Cover the client with a warm blanket.
Increase the IV fluid rate.
Reassure the client.
Compare the reading to the preoperative value.
The Correct Answer is D
Choice D: Comparing the reading to the preoperative value is the first action that the nurse should take because it can help determine if the client's blood pressure is normal for them or if it indicates hypotension, which can be a sign of hemorrhage, shock, or infection.
Choice a is not correct because covering the client with a warm blanket is not the first action that the nurse should take, but rather an intervention that can help prevent hypothermia and shivering, which can increase oxygen demand and blood loss.
Choice b is not correct because increasing the IV fluid rate is not the first action that the nurse should take, but rather an intervention that can help restore fluid volume and blood pressure, if indicated by other data and prescribed by the provider.
Choice c is not correct because reassuring the client is not the first action that the nurse should take, but rather an intervention that can help reduce anxiety and stress, which can affect blood pressure and heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C Hemoglobin 8.6 g/dL indicates the nurse should notify the provider because it is below the normal range of 12 to 18 g/dL and suggests blood loss or anemia, which can impair oxygen delivery to tissues and affect wound healing.
Choice a is not correct because blood glucose 98 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 70 to 110 mg/dL and does not indicate hyperglycemia or hypoglycemia, which can affect recovery.
Choice b is not correct because BUN 18 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 10 to 20 mg/dL and does not indicate renal impairment or dehydration, which can affect fluid and electrolyte balance.
Choice d is not correct because potassium 3.5 mEq/L does not indicate the nurse should notify the provider because it is within the normal range of 3.5 to 5 mEq/L and does not indicate hypokalemia or hyperkalemia, which can affect cardiac function and muscle contraction.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Applying an SPF 30 sunscreen before gardening is an appropriate statement, as it indicates that the client understands the importance of protecting their skin from sun exposure, which can trigger or worsen lupus flare-ups and cause skin rashes or lesions.
Choice B reason: Cleansing reddened areas of their face with an astringent is not an appropriate statement, as it indicates that the client does not understand that astringents can irritate or dry out their skin and aggravate their condition. The client should use mild soap and water or moisturizing cleanser to wash their face gently.
Choice C reason: Gently patting their skin dry after bathing is an appropriate statement, as it indicates that the client understands how to avoid rubbing or scratching their skin, which can cause injury or infection and delay healing.
Choice D reason: Applying lotion to their skin twice daily is an appropriate statement, as it indicates that the client understands how to keep their skin hydrated and prevent dryness or cracking that can increase their risk of infection or inflammation.
Choice E reason: Limiting time on tanning beds to 10 minutes is not an appropriate statement, as it indicates that the client does not understand that tanning beds emit ultraviolet rays that can harm their skin and worsen their lupus symptoms. The client should avoid tanning beds altogether and wear protective clothing and sunglasses when outdoors.
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