A nurse on a medical surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

A client who is scheduled for surgery in 2 hr

A client whose blood pressure is 160/90 mm Hg and reports a headache

A client who is postoperative and reports intermittent nausea

A client who is postoperative and has a Jackson Pratt drain

Answer and Explanation

The Correct Answer is B

A.   Incorrect. While a client scheduled for surgery is important, addressing the client with elevated blood pressure and a headache takes priority.
B.   Correct. The client with elevated blood pressure and a headache requires immediate assessment, as these symptoms could indicate a hypertensive crisis or other serious complications.
C.   Incorrect. While addressing postoperative nausea is important, the client with elevated blood pressure and headache requires more immediate attention.
D.   Incorrect. A client with a Jackson Pratt drain may need care and assessment, but a client with elevated blood pressure and a headache has a more urgent need for evaluation.

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Correct Answer is B

Explanation

A. Patterned-paced breathing might help with pain management, but it's not specific to changing positions.
B. Correct. Splinting the incision with a pillow provides support and reduces strain when changing positions, minimizing discomfort.
C. Counterpressure to the back might be helpful during contractions, but it's not specific to postoperative pain with position changes.
D. While reducing position changes might be initially suggested, it's important for postoperative clients to move to prevent complications like deep vein thrombosis. Providing strategies to manage pain during position changes is more appropriate.

A. 16 lb B. 32 lb C. 24 lb D. 8 lb

Correct Answer is A

Explanation

A. Correct. For a client with a pre-pregnancy BMI of 30.5 (considered obese., an acceptable weight gain during pregnancy is typically around 1120 pounds (59 kg., making 16 pounds an appropriate option within this range.
B. Incorrect. A weight gain of 32 pounds would be considered excessive for a client with a pre-pregnancy BMI of 30.5.
C. Incorrect. A weight gain of 24 pounds might still fall within an acceptable range, but for a client with a pre-pregnancy BMI of 30.5, a weight gain of 16 pounds is a more appropriate option.
D. Incorrect. A weight gain of 8 pounds would likely be insufficient for a client with a pre-pregnancy BMI of 30.5.

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A nurse on a medical surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Nursing Test Bank

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