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 A

Explanation

Choice A reason:

The correct answer is a) because auscultating bowel sounds can help assess for the return of gastrointestinal function and identify potential complications such as ileus, which can cause abdominal pressure and nausea.

Choice B reason: Ambulating the client is important for postoperative recovery but does not directly address the symptoms of abdominal pressure and nausea.

Choice C reason: Palpating the abdomen is also important but should be done after auscultation to avoid altering bowel sounds.

Choice D reason: Measuring urine output is important for monitoring renal function but does not directly address the symptoms of abdominal pressure and nausea.

A. Observe the color of the extremity. B. Notify the healthcare provider of the assessment finding. C. Discontinue elevating the client's affected extremity. D. Document the neurovascular assessment as normal.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because observing the color of the extremity provides additional information about circulation and potential complications such as compartment syndrome.

Choice B reason: Notifying the healthcare provider is necessary if there are abnormal findings.

Choice C reason: Discontinuing elevation is not necessary unless there are signs of compromised circulation.

Choice D reason: Documenting the assessment as normal comes after completing a thorough assessment.

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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

Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

Correct Answer is A

Explanation

While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?

Correct Answer is A

Explanation

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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?

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