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.
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Related Questions
Correct Answer is D
Explanation
A. Administer 10% sodium chloride via rapid infusion: Rapid infusion of high concentrations of sodium chloride can be dangerous and is not the standard treatment for severe hyponatremia.
B. Administer intranasal antidiuretic hormone: This would not be appropriate for correcting severe hyponatremia and could potentially worsen the condition.
C. Encourage oral fluid intake: For severe hyponatremia, oral fluid intake might not be sufficient and could exacerbate the condition if there is fluid overload.
D. Place the client on seizure precautions: This is the correct choice. Severe hyponatremia (sodium < 120 mEq/L) can lead to neurological symptoms and seizures, so implementing seizure precautions is crucial for safety.
Correct Answer is A
Explanation
A. Discontinue the intravenous line: The presence of tenderness and a red streak suggests phlebitis or possibly an early sign of infection. The first and most important step is to discontinue the IV line to prevent further irritation or infection.
B. Complete an incident report: While documentation is important, it is not the first action to take. Immediate attention should be given to the client’s physical condition before completing any paperwork.
C. Start a new IV in the right hand: While starting a new IV is necessary for continued therapy, the first action should be to remove the current IV line to prevent further complications. Starting a new IV can be done immediately afterward.
D. Place a warm compress over the site: A warm compress can help alleviate pain and reduce inflammation, but the priority action is to discontinue the IV line to stop further damage or infection.
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