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A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 110/78 with a pulse change of 68 to 84. The first action indicated by the nurse is to


A) assess the patient's dressing.
B) check the patient's temperature.
C) increase the oxygen flow rate.
D) raise the IV infusion rate.

E) B) and C)
F) All of the above

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The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the


A) patient uses the spirometer 10 times every hour.
B) patient's temperature is less than 100.4° F orally.
C) patient drinks 2 to 3 L of fluid in 24 hours.
D) patient's breath sounds are clear to auscultation.

E) A) and D)
F) B) and D)

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The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the PACU 10 minutes previously. Which action should the nurse take first?


A) Perform the jaw-thrust maneuver.
B) Increase the oxygen flow rate.
C) Suction the patient's mouth.
D) Elevate the patient's head.

E) B) and C)
F) A) and D)

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The nasogastric (NG) tube is removed on the second postoperative day for a patient who had abdominal surgery. A clear liquid diet is ordered. Four hours later, the patient complains of abdominal distention and sharp, cramping gas pains. The most appropriate nursing action is to


A) place the patient on NPO status.
B) assist the patient to ambulate in the hall.
C) administer the ordered as-needed morphine sulfate.
D) reinsert the NG tube.

E) None of the above
F) B) and C)

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