A nurse is collecting data from a client who is 8 hours postoperative following abdominal surgery. The client's blood pressure is 94/56 mm Hg. Which of the following actions should the nurse take first?
Increase the IV flow rate
Reassure the client
Compare the reading to the preoperative value
Cover the client with a warm blanket
The Correct Answer is C
Choice A reason: Increasing the IV flow rate may be necessary if the blood pressure is significantly lower than the preoperative value and there are signs of hypovolemia.
Choice B reason: Reassuring the client is important, but it should not be the first action before assessing the clinical significance of the blood pressure reading.
Choice C reason: Comparing the current blood pressure with the preoperative value helps determine the next steps in management and whether the change is within expected limits.
Choice D reason: Covering the client with a warm blanket may be appropriate if the client is feeling cold, but it is not the first action to take in response to the blood pressure reading.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:Aspiration pneumonia is typically caused by inhalation of foreign material into the lungs rather than by contagious pathogens. Therefore, standard precautions are usually sufficient unless a secondary infection with a transmissible organism is present.
Choice B reason: Applying petroleum jelly to the client's nares may provide comfort but is not a priority in the care plan.
Choice C reason: Maintaining the client in a supine position is contraindicated as it can increase the risk of aspiration.
Choice D reason: Clients with hypoxia may experience symptoms such as confusion, restlessness, and dizziness, which can increase the risk of falls. Implementing fall precautions is a proactive measure to ensure patient safety in this context.
Correct Answer is A
Explanation
Choice A Reason:
Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive system is functioning and that gas is moving through the colostomy. This is a positive indicator of colostomy function.
Choice B Reason:
Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area, which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.
Choice C Reason:
Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of gastrointestinal function, but it might not specifically confirm the functionality of the colostomy itself.
D. Absent bowel sounds
Absent bowel sounds might be present immediately postoperatively due to the effects of anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of colostomy function.
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