The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?
Start an IV of DSNS with 40 mEq KCI at 125 mL/hr
Elevate the feet and lower the head
Call the surgeon and report the vital signs
Monitor the vital signs every 15 minutes
The Correct Answer is B
A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will increase my fluid and fiber intake while I am taking iron tablets.": This statement is correct as increasing fluid and fiber can help manage constipation, a common side effect of iron supplementation.
B. "I will take the tablets with water an hour before eating.": This is correct because taking iron supplements on an empty stomach can improve absorption, and water helps dissolve the tablets.
C. "I will immediately call my health care provider if my stools turn green.": This statement indicates a misunderstanding, as green stools are a common and harmless side effect of iron supplements. They are not typically a cause for concern unless accompanied by other symptoms.
D. "I will take a stool softener if I occasionally feel constipated.": This is a correct and appropriate approach, as stool softeners can help alleviate constipation caused by iron supplements.
Correct Answer is D
Explanation
A. Hypomagnesemia: While hypomagnesemia can cause weakness and other symptoms, it is less commonly associated with fluid volume deficit compared to other imbalances in this context.
B. Hyperphosphatemia: Hyperphosphatemia is typically associated with renal failure or specific conditions, but it does not directly correlate with fluid volume deficit or the symptoms described.
C. Hypokalemia: Hypokalemia can cause weakness and abdominal pain, but it is less likely to be directly associated with the type of symptoms presented in this oncology context.
D. Hypercalcemia: This is the correct choice. Hypercalcemia, often associated with bone metastases, can lead to weakness, abdominal pain, and dehydration, as well as contribute to fluid volume deficit through increased urinary calcium excretion and renal effects.
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