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 A
Explanation
Choice A reason: Oxybutynin is an anticholinergic drug that relaxes the muscles of the bladder and reduces spasms, urgency, and frequency of urination. It is used to treat overactive bladder and urinary incontinence.
Choice B reason: Oxybutynin does not increase tissue perfusion in the lungs, as it has no effect on the respiratory system. It can actually cause dry mouth, nasal congestion, and blurred vision as side effects.
Choice C reason: Oxybutynin does not increase venous return to the heart, as it has no effect on the cardiovascular system. It can actually cause tachycardia, palpitations, and hypertension as side effects.
Choice D reason: Oxybutynin does not relax the muscles of the colon, as it has no effect on the gastrointestinal system. It can actually cause constipation, nausea, and abdominal pain as side effects.
Correct Answer is A
Explanation
Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.
Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.
Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.
Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.
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