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    HESI RN Medical surgical proctored exam

    The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

    Explanation & Rationale

    Choice A reason: Ensuring the IV solution is infusing at the prescribed rate is important, but it is not the first action the nurse should take. The symptoms the client is exhibiting—low blood pressure, tachycardia, restlessness, and irritability—are indicative of potential hypovolemic shock, likely due to bleeding. Immediate assessment for bleeding is more critical.Choice B reason: Notifying the healthcare provider of the findings is essential, but it should be done after assessing the client for signs of bleeding. The nurse needs to quickly identify the source of the client’s symptoms before contacting the healthcare provider to provide a complete and accurate report of the situation.Choice C reason: Checking under the back for evidence of bleeding is the correct first action. The client's symptoms suggest they might be experiencing hypovolemic shock due to postoperative bleeding. Identifying whether there is visible bleeding can help determine the next steps in managing the client's condition and providing appropriate interventions.Choice D reason: Listening to lung sounds is important in a comprehensive assessment but is not the priority in this scenario. The client's symptoms strongly indicate a potential bleeding issue, so checking for evidence of bleeding should come first to promptly address the most life-threatening concern.

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