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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: A decrease in pulse rate is not typically associated with dehydration. Dehydration would more likely cause an increase in pulse rate due to the body's attempt to maintain adequate blood flow.

Choice B reason: Confusion in older adults can be a sign of many conditions, including dehydration, as it affects the normal physiological processes and can impair cognitive function.

Choice C reason: Cool, clammy skin can be associated with dehydration but is more commonly seen in shock or hypoperfusion states.

Choice D reason: An increase in blood pressure is not a typical sign of dehydration. Dehydration would more likely cause a decrease in blood pressure due to a reduction in blood volume.

A. "I have purchased a stoma cap I can use when needed." B. "My partner empties my pouch for me every morning." C. "I am embarrassed by the odor that comes from my colostomy." D. "I miss going to my church meetings like I used to do."

Correct Answer is A

Explanation

Choice A reason: This statement reflects acceptance as the client is taking proactive steps to manage their colostomy independently, which is indicative of adapting to the change in body function.

Choice B reason: While having a partner's support is beneficial, this statement does not necessarily indicate acceptance. It could suggest reliance on others rather than selfcare and acceptance.

Choice C reason: Feeling embarrassed by the colostomy's odor suggests that the client is still struggling with the social implications of their condition, which is not indicative of the acceptance stage.

Choice D reason: Expressing a sense of loss about previous activities, such as attending church meetings, indicates that the client may be in the earlier stages of grieving, such as denial or bargaining, rather than acceptance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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