The nurse is assigned to assist in caring for a client who recently returned from the operating room (OR)
On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which of the following actions should the nurse plan to take first? 1. Shake the client gently to arouse.
2. Call the surgeon immediately.
3. Cover the client with a warm blanket.
4. Recheck the vital signs in 15 minutes.
4
Rationale: A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. Warm blankets are applied to maintain the client's body temperature. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately.
You might also like to view...
A team of community health nurses have been commissioned to plan and implement a community-based health promotion initiative aimed at addressing obesity
During the planning stages, the nurses should be aware that the prevalence of obesity is highest in which of the following groups? A) Caucasian women B) Caucasian men C) African American women D) African American men
A client with chronic lymphangitis of the lower extremities asks the nurse how often she should wear elastic stockings. The nurse should explain:
1. "It is only necessary to wear them if you notice an increase in swelling." 2. "You should wear them when your legs feel heavy or are painful for you." 3. "You should wear them at all times, only taking them off to bathe." 4. "It is best to wear them during your waking hours and to remove them when sleeping."
To assess a patient's ability to identify the taste of a sweet substance, you would apply the flavor-soaked cotton swab
a. to the tip of the tongue. b. to the back of the tongue and the soft palate. c. along the borders of the tongue. d. on the top of the hard palate.
Which of the following is true of the mechanism of action of aldosterone?
A. Aldosterone increases the discharge of sodium ions and water into the urine. B. Aldosterone increases the reabsorption of potassium ions and water; in exchange, sodium ions are transported into the urine. C. Aldosterone increases the reabsorption of sodium ions and water; in exchange, potassium ions are transported into the urine. D. None of these are correct.