A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?

Correct Answer: A

Rationale: The correct answer is A: Call the Rapid Response Team. A significant drop in blood pressure from 142/76 mm Hg to 88/50 mm Hg indicates a potential life-threatening condition like hypovolemic shock. Calling the Rapid Response Team allows for immediate assessment and intervention to stabilize the client. Other choices are incorrect because documenting and monitoring without intervention can lead to deterioration, notifying the primary care provider may cause delays in critical care, and repeating the blood pressure measurement in 15 minutes may worsen the client's condition if urgent intervention is needed.

Correct Answer: B

Rationale: The correct answer is B: Ensuring client safety. This is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor because safety is the foundation of nursing care. Ensuring client safety involves preventing harm, maintaining a safe environment, and implementing appropriate interventions. Attending to holistic client needs (A) and providing client-focused care (D) are important aspects of nursing practice but ensuring client safety takes precedence. Avoiding medication errors (C) is crucial for patient safety but is just one aspect of ensuring overall client safety.

Correct Answer: A

Rationale: The correct answer is A: Bring a list of all medications and their purposes. This is important as it helps prevent medication errors during the surgical procedure. By having a list of medications and their purposes, the healthcare team can ensure they are administering the correct medications and dosages. This also helps in preventing drug interactions or allergies. Option B (Keep the doctor's phone number close by) may be helpful in case of emergencies, but it does not directly address preventing errors during the surgical procedure. Option C (Ensure all providers wash their hands before entering the room) is important for infection control but is not specifically related to preventing errors. Option D (Document the name of each caregiver who enters the room) is not as critical as having a list of medications, as it does not directly impact the safety and well-being of the client during the surgical procedure.

Correct Answer: A

Rationale: The correct answer is A because asking if the client has questions before signing a consent form shows respect for autonomy by allowing the client to make an informed decision. This action promotes the client's right to self-determination and involvement in the decision-making process. Choice B focuses on providing information when questioned but may not actively involve the client in the decision-making process. Choice C refers to honoring promises and not necessarily respecting autonomy. Choice D relates to fairness but does not directly address autonomy or the client's decision-making ability.

Correct Answer: B

Rationale: The correct answer is B: Don't make assumptions about their health needs. Rationale: 1. LGBTQ individuals have diverse health needs. 2. Making assumptions can lead to inappropriate or inadequate care. 3. By not assuming, you show respect and promote open communication. 4. This approach fosters trust and ensures individualized care. Other choices: A: Avoiding questions can hinder understanding and communication. C: Generalizing that most LGBTQ individuals do not share information is inaccurate. D: Differences exist in the LGBTQ community that should be acknowledged for effective communication.