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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Related Questions
Correct Answer is D
Explanation
A. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke": This is incorrect as glucocorticoids are not typically used to reduce stroke risk; they are more commonly used to manage inflammation and other conditions.
B. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke": This is incorrect because having a total cholesterol level below 200 mg/dL is generally considered desirable and lowers the risk of stroke.
C. "My risk for a stroke increases if my HbA1c level is 6 percent or less": This is incorrect because an HbA1c level of 6 percent or less is generally considered well-managed for diabetes and does not increase stroke risk; higher levels are more concerning.
D. "I can decrease my risk for a stroke by losing excess weight": This is correct as losing excess weight can reduce the risk of stroke by improving overall cardiovascular health and managing diabetes.
Correct Answer is D
Explanation
A. "You should focus on recovering from your cancer right now.": This is incorrect because it dismisses the client's concerns about sexual function and does not address their immediate emotional and psychological needs.
B. "There are other ways to express intimacy besides intercourse.": This is a valid point, but it does not directly address the specific concern about maintaining sexual function, which the client may need to hear for reassurance.
C. "I'm sure any partner will understand that you have no control over this.": This is incorrect because it does not provide specific reassurance about the effects of the surgery on sexual function and can come across as dismissive.
D. "The removal of a single testicle will not prevent you from having an erection.": This is correct as the removal of one testicle does not generally impact the ability to achieve or maintain an erection, and it provides specific reassurance about sexual function.
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