After administering anesthesia to the patient, the nurse notices a sudden drop in blood pressure. What is the nurse's priority action?

Correct Answer: B

Rationale: The nurse's priority action after noticing a sudden drop in blood pressure after administering anesthesia is to assess the patient's airway, breathing, and circulation (ABCs). This is crucial to determine the immediate cause of the sudden drop in blood pressure and to ensure the patient's safety and stability. Assessment of the ABCs will help identify any potential airway obstruction, respiratory distress, or circulatory issues that may be contributing to the drop in blood pressure. Once the assessment is done, appropriate interventions can be initiated to stabilize the patient's condition. Administering vasopressors, documenting the blood pressure readings, and notifying the anesthesiologist are important actions but assessing the ABCs takes precedence in this situation to ensure the patient's immediate needs are addressed.

Correct Answer: C

Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.

Correct Answer: D

Rationale: Speaking up on behalf of the patient to ensure their needs are met is a key action that demonstrates advocacy by the nurse. Advocacy involves actively supporting and safeguarding the rights of the patient, ensuring that their best interests are being considered within the healthcare system. This may include advocating for appropriate treatment, services, resources, or respect for the patient's autonomy and decision-making. By speaking up for the patient, the nurse is acting as their voice and championing their well-being.

Correct Answer: C

Rationale: Collaborating with interdisciplinary team members to develop a comprehensive care plan demonstrates effective care coordination. In complex healthcare situations, involving various healthcare providers such as physicians, specialists, therapists, social workers, and others is crucial to ensure that all aspects of the patient's care are addressed holistically. By working together, healthcare professionals can share information, expertise, and insights to develop a well-rounded care plan that considers all aspects of the patient's needs. This collaborative approach helps promote better outcomes for the patient and enhances overall care coordination. It also helps to ensure that the patient's preferences and values are taken into account when developing the care plan.

Correct Answer: D

Rationale: The correct action to prioritize during the initial assessment when preparing to assist with a cardiopulmonary resuscitation (CPR) procedure for a patient in cardiac arrest is to assess the patient's airway, breathing, and circulation (ABCs). This involves quickly checking the patient's airway for any obstructions, assessing their breathing for signs of breathing difficulties or absence of breathing, and evaluating their circulation by checking for a pulse. This step is crucial in determining the need for immediate intervention, such as clearing the airway, providing rescue breaths, or initiating chest compressions. By prioritizing the assessment of the ABCs, the nurse can promptly identify and address life-threatening issues to improve the patient's chances of survival during a cardiac arrest situation.