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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The correct answer is a) because using antibacterial soap can be too harsh and irritating for the skin that is undergoing radiation treatment. Gentle cleansing with mild soap is recommended to avoid skin irritation.
Choice B reason: Drying the area with patting motions is appropriate as it helps prevent further irritation to the sensitive skin.
Choice C reason: Applying prescribed lotions is recommended to keep the skin moisturized and help with any radiation-induced dryness or irritation.
Choice D reason: Wearing clothing to cover the radiation site can protect the area from sun exposure and further irritation, which is appropriate care for the skin.
Correct Answer is B
Explanation
Choice A reason: Using extra pillows may help with comfort but is not the basis of the nurse's response to the concern about thoracentesis.
Choice B reason:
The correct answer is b) because during thoracentesis, the client is positioned upright, which helps ease breathing and access the pleural space.
Choice C reason: While the procedure may be brief, this response does not directly address the concern about breathing.
Choice D reason: Orthopnea can be caused by conditions other than anxiety and should be addressed appropriately.
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