A nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient's blood pressure is 90/60 mm Hg, and the apical pulse is 108 beats/min. What should be the nurse's first action?
a. Check the dressing for bleeding.
b. Notify the registered nurse (RN).
c. Document the vital signs.
d. Increase the rate of infusion of intraven-ous fluids.
A
A decrease in blood pressure and tachycardia could indicate postoperative bleeding. The first ac-tion of the nurse should be to check the dressing and then report to the RN.
You might also like to view...
The nurse considers which of the following classifications of law when administering IV therapy?(Select all that apply) Standard Text: Select all that apply
1. Criminal law 2. Common law 3. Civil law 4. Negligence 5. Federal law
The nurse is caring for a client who develops a fever and productive cough after having an appendectomy. Which prescriptions should the nurse expect from the healthcare provider for this health problem?
Select all that apply. A) Sputum cultures B) Antibiotics C) Chest physiotherapy D) Bronchial washing for culture E) Isolation precautions
The nurse anticipates the needs of several patients being cared for. The nurse is correct in anticipating that the patient who may experience the highest level of pain is a:
a. 23 year old experiencing pain related to a broken femur. b. 45 year old experiencing pain following a laparoscopic cholecystectomy. c. 67 year old experiencing chronic back pain. d. 89 year old experiencing pain related to osteoarthritis.
As the unit manager, you spend a day performing direct patient care and work with a new system that is designed to capture patient documentation at the bedside
During discussions with staff while giving care, you discover that the number of screens that need to be opened during documentation makes charting more complex and time-consuming than traditional manual charting approaches. On the basis of this feedback, you: a. Assume that the system is doing what it needs to do. b. Provide reassurance to staff that the unit has achieved its goals in implementation of the system. c. Ask some of the staff if they have had similar experiences with the system. d. Consult chart audit data and end user consultation reports to determine if errors and problems are occurring.