Difficulty: Medium
Average Score: 65%
Simulated
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 tachycardic, restless, and irritable. Which action should the nurse perform first?
Correct answer
A
Rationale
The correct answer is A because low blood pressure and tachycardia suggest bleeding, which checking under the back can confirm. Choice B is not the priority. Choice C is secondary. Choice D follows assessment.