Author Question: A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 ... (Read 80 times)

WWatsford · **on:** Jun 25, 2018

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection.

What should the nurse assess next?

a.
Cognitive status
b.
Family stress
c.
Nutrition status
d.
Psychosocial status

Question 2

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?

a. Assess the client's blood pressure.
b. Perform hand hygiene and apply gloves.
c. Reinforce the dressing with a clean one.
d. Remove the dressing to assess the wound.

Jossy · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
After ensuring the client's physiologic status is stable, these manifestations should lead the nurse to assess the client's psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.

Answer to Question 2

ANS: B
Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection.