A postoperative patient reports dizziness when sitting up. The patient's blood pressure is 88/58 mmHg, heart rate is 112 bpm, and respiratory rate is 18 breaths per minute. What is the nurse's priority action?
Select one:

Connect the patient to a cardiac monitor

Administer IV fluids as ordered

Place the patient in a supine position and notify the provider

Document the findings and continue to monitor

Answer and Explanation

The Correct Answer is C

A. While monitoring is important, it is not the priority when the patient is symptomatic with hypotension and dizziness.
B. IV fluids may be necessary to treat hypotension, but positioning the patient safely and notifying the provider comes first to prevent falls or further deterioration.
C. The patient is showing signs of orthostatic hypotension and compensatory tachycardia. Placing the patient in a supine position helps restore cerebral perfusion and stabilize blood pressure. Immediate notification of the provider allows for prompt medical intervention.
D. Documentation and monitoring are important, but intervention is needed immediately due to symptomatic hypotension.

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Correct Answer is C

Explanation

A. Portal hypertension leads to complications like varices and ascites but is not the direct cause of encephalopathy.
B. Ascites is a fluid accumulation in the abdomen related to portal hypertension and low albumin, not directly linked to altered mental status.
C. High ammonia levels are the primary cause of hepatic encephalopathy in cirrhosis. The damaged liver is unable to effectively convert ammonia to urea, resulting in ammonia buildup in the blood, which affects brain function and leads to confusion, lethargy, or even coma.
D. Vitamin K deficiency contributes to bleeding problems, not encephalopathy.

A. Low heart rate B. High blood pressure C. High respiration rate D. Low respiration rate E. Fever F. High heart rate G. Low blood pressure

Correct Answer is ["C","E","F","G"]

Explanation

A. Septic shock typically causes tachycardia (increased heart rate), not bradycardia.

B. Septic shock is usually associated with hypotension due to widespread vasodilation and capillary leak.

C. Tachypnea (increased respiratory rate) is a compensatory response to metabolic acidosis in septic shock.

D. A decreased respiratory rate is not characteristic of septic shock and may suggest impending respiratory failure.

E. Fever is a common sign of systemic infection and early sepsis.

F. Tachycardia is an early sign of septic shock due to compensatory mechanisms trying to maintain perfusion.

G. Hypotension is a hallmark of septic shock, indicating inadequate tissue perfusion.

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A postoperative patient reports dizziness when sitting up. The patient's blood pressure is 88/58 mmHg, heart rate is 112 bpm, and respiratory rate is 18 breaths per minute. What is the nurse's priority action? Select one:

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Naxlex Comprehensive Predictor Exams

What is the major cause of encephalopathy in cirrhosis?

Correct Answer is C

Explanation

The nurse is assessing vital signs of a patient who has peritonitis. Which of the following vital signs indicate septic shock? Select all that apply.

Correct Answer is ["C","E","F","G"]

Explanation

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A postoperative patient reports dizziness when sitting up. The patient's blood pressure is 88/58 mmHg, heart rate is 112 bpm, and respiratory rate is 18 breaths per minute. What is the nurse's priority action?
Select one: