One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Increase frequency of BP assessments.

Encourage the client to breathe deeply.

Check the abdominal surgical dressing.

Review the client's baseline BP trends.

Answer and Explanation

The Correct Answer is C

Choice A reason: Increasing the frequency of BP assessments is important to monitor the client's condition, but it does not address the potential cause of the drop in blood pressure.

Choice B reason: Encouraging the client to breathe deeply is useful for overall respiratory function but does not address the specific issue of the dropping blood pressure.

Choice C reason:

The correct answer is c) because checking the abdominal surgical dressing can help identify if there is postoperative bleeding or other complications at the surgical site, which could be causing the drop in blood pressure.

Choice D reason: Reviewing the client's baseline BP trends provides useful information but does not address the immediate potential cause of the blood pressure change.

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Correct Answer is D

Explanation

Choice A reason: High-potassium foods should be monitored but are not the primary concern for AGN.

Choice B reason: Protein intake should be managed but not necessarily increased.

Choice C reason: Avoiding high-carbohydrate foods is not specific to AGN management.

Choice D reason:

The correct answer is d) because restricting sodium intake helps manage fluid retention and hypertension, which are common issues in AGN.

A. Keep room temperature cool. B. Determine the client's food preferences. C. Maintain a patent intravenous site. D. Teach the client relaxation techniques.

Correct Answer is C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

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One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Nursing Test Bank

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When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?

Correct Answer is D

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