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 ["2"]

Explanation

Calculation steps:

Step 1: Identify the dosage required. 20 mg

Step 2: Identify the concentration available. 10 mg/mL

Step 3: Calculate the volume to be administered. 20 mg ÷ 10 mg/mL

Result: 2 mL

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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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

Naxlex Comprehensive Predictor Exams

A client with edema receives a prescription for a one-time dose of furosemide 20 mg IV. The medication is available in a 10 mg/mL vial. How many mL should the nurse administer? (Enter numerical value only.)

Correct Answer is ["2"]

Explanation

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is C

Explanation

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