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 D
Explanation
A. Offer meals to the client following physical activity: This is incorrect as eating after physical activity might be challenging for a client with dysphagia, and it is better to provide meals when the client is at rest.
B. Provide peanut butter on crackers as a snack choice: This is incorrect because peanut butter and crackers might be difficult to swallow and could pose a choking risk for someone with dysphagia.
C. Provide liquids in a cup with a straw: This is incorrect as straws can cause liquids to be aspirated more easily, which is a risk for clients with dysphagia.
D. Instruct the client to tilt his head forward when swallowing: This is correct because tilting the head forward can help prevent aspiration and facilitate safer swallowing in clients with dysphagia.
Correct Answer is A
Explanation
A. Increase the IV flow rate: This is correct as the client’s low blood pressure could indicate hypovolemia. Increasing the IV flow rate can help improve blood volume and blood pressure, addressing a potential cause of hypotension.
B. Cover the client with a warm blanket: While this could help if the client is hypothermic, it does not address the immediate issue of low blood pressure.
C. Compare the reading to the preoperative value: While this can provide context, it does not directly address the current low blood pressure situation.
D. Reassure the client: Reassuring the client is important but does not address the urgent issue of low blood pressure.
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