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A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
- A. Administer an IV fluid bolus.
- B. Check the surgical site for bleeding.
- C. Place the client in a Trendelenburg position.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.
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Following a gastric resection, a 70-year-old male client is admitted to the Post-Anesthesia Care Unit (PACU). The client was extubated prior to leaving the OR suite. Upon arrival at the PACU, the nurse should first:
- A. check the client's airway to feel for the amount of air exchange, noting the rate, depth, and quality of respirations.
- B. obtain pulse and blood pressure readings, noting the rate and quality of the client's pulse.
- C. reassure the client that his surgery is over and that he is in the recovery room.
- D. review the doctor's orders to administer any medications ordered.
Correct Answer: A
Rationale: Adequate air exchange and tissue oxygenation depends upon competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but is secondary to airway management. Re-orienting a client to time, place, and person and knowing that their surgery is over is important, but is secondary to airway management and taking vital signs. Airway management takes precedence over the physician's orders, unless the orders specifically relate to airway management.
A client with chronic obstructive pulmonary disease (COPD) who has been receiving oxygen therapy at 2 L/min now has a respiratory rate of 10 breaths/min. What action should the nurse take first?
- A. Increase the oxygen flow rate to 4 L/min.
- B. Administer a bronchodilator via nebulizer.
- C. Encourage the client to take deep breaths.
- D. Assess the client's mental status and level of consciousness.
Correct Answer: D
Rationale: The correct answer is D, assessing the client's mental status and level of consciousness. This is the first action to take because a respiratory rate of 10 breaths/min in a COPD client receiving oxygen therapy may indicate respiratory depression or impending respiratory failure. Assessing mental status and level of consciousness can help determine if the client is experiencing hypoxia. Increasing oxygen flow rate (A) without assessing the client first can be dangerous if the client is retaining carbon dioxide. Administering a bronchodilator (B) may not address the underlying issue of respiratory depression. Encouraging deep breaths (C) may not be appropriate if the client is in respiratory distress.
10. Priority Decision: A bedridden patient tells the nurse she has low back pain and asks if the area could be massaged. What is the best action by the nurse?
- A. Ask the patient if she has ever tried acupuncture for back pain.
- B. Explain to the patient that massage may be done only by a licensed therapist and offer a PRN analgesic instead.
- C. Comfortably position the patient to expose the area and massage the back with effleurage and petrissage strokes.
- D. Call the physical therapy department to request that a physical therapist see the patient to provide a therapeutic massage.
Correct Answer: C
Rationale: Providing a gentle massage using effleurage and petrissage strokes (option C) is within the scope of nursing practice and can provide immediate relief to the patient.
A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct Answer: C
Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.
When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.