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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While nausea and vomiting are common side effects of many chemotherapy agents, this is not specific to vesicants, which are drugs that can cause tissue damage if they leak outside the vein.
B. Vesicant chemotherapy agents can cause severe tissue damage, necrosis, and ulceration if they extravasate (leak into surrounding tissue). Close monitoring of the IV site for signs of redness, swelling, or pain is essential.
C. This may indicate gastrointestinal or bladder irritation from other types of chemotherapy agents, but it is not the hallmark concern with vesicants.
D. This is unrelated to vesicant properties. Orthostatic hypotension may occur from dehydration or autonomic effects, but not from vesicant infiltration.
Correct Answer is A
Explanation
A. The circulating nurse is responsible for ensuring that all preoperative documentation is complete, including verifying that the informed consent form is signed and that the surgical site is correctly marked according to safety protocols (e.g., surgical time-out).
B. The surgeon is responsible for obtaining informed consent and marking the site, but it is the circulating nurse’s duty to verify that this has been done before the procedure.
C. The scrub nurse maintains sterility and handles instruments, but is not responsible for verifying consent or site marking.
D. The anesthesiologist manages anesthesia and airway concerns, not documentation or site verification.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.