A nurse is collecting data from a client who is 8 hr 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.
Cover the client with a warm blanket.
Compare the reading to the preoperative value.
Reassure the client.
The Correct Answer is A
A. Increase the IV flow rate: This is correct as the client's blood pressure is low, which could indicate hypovolemia or shock. Increasing the IV flow rate can help improve blood volume and blood pressure.
B. Cover the client with a warm blanket: While this can help with hypothermia, it does not address the immediate concern of low blood pressure.
C. Compare the reading to the preoperative value: Comparing to the preoperative value can provide context but does not directly address the current low blood pressure.
D. Reassure the client: Reassuring the client is important but not the first priority. Addressing the physiological issue of low blood pressure should be the initial focus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Elevate the head of the bed 45° before starting the CPM device: This is incorrect as elevating the head of the bed is not a necessary preparation for using the CPM device. The device should be used according to the specific postoperative guidelines.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect because the frame joint should generally be in an extended position to properly align the leg for movement through the device's range of motion.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct because proper alignment of the knee joint with the CPM device's frame joint is crucial to ensure that the device functions correctly and promotes effective range-of-motion exercises.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect because the degree of flexion should be adjusted according to the prescribed protocol by the healthcare provider and should not be self-adjusted by the client.
Correct Answer is C
Explanation
A. "You will not become fatigued when you use assistive devices": This is incorrect as clients may still experience fatigue even with assistive devices, and energy conservation strategies should be discussed.
B. "Plan to hire a home care aide to perform all of your ADLs": This is not advisable as the goal is to encourage as much independence as possible; assistance should be provided based on need, not all tasks.
C. "Install grab bars in your shower to assist with your balance": This is correct as installing grab bars can enhance safety and support the client’s balance, helping to prevent falls and injuries.
D. "Place a towel in the shower to prevent slipping": This is not as effective as grab bars and may not provide adequate support or prevent slips as well as proper bathroom modifications.
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