Practice Question
One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?
Answer Choices:
Correct Answer:
Check the abdominal surgical dressing.
Rationale:
🌟 A sudden drop in blood pressure following major abdominal surgery raises concern for internal or external bleeding.
🌟 The nurse’s first action should be to assess the surgical site and dressing for evidence of hemorrhage, such as fresh bleeding, saturation, or distention.
🌟 Postoperative hemorrhage is a life-threatening complication that requires rapid detection and intervention to prevent hypovolemic shock.
🌟 While monitoring BP trends and increasing frequency of assessments are important, they do not address the cause of the hypotension.
🌟 Encouraging deep breathing is unrelated to the acute drop in BP and does not address the immediate risk.
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This question is from HESI RN Med-Surg Fall 2024. which contains 40 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi MedSurg
- Answer Choices: 4