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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A, Hot cocoa.
Choice A rationale:
Hot cocoa contains the least amount of caffeine among the options provided.A standard 240 mL (8 oz) cup of hot cocoa contains approximately 5 mg of caffeine. This is significantly less than the other beverages listed. Hot cocoa is made by adding cocoa powder and sugar or chocolate syrup to hot milk.The drink contains very little cacao, so the caffeine content is very low. Therefore, if a client is looking to reduce their dietary caffeine intake, hot cocoa would be a suitable choice.
Choice B rationale:
A cola soft drink contains more caffeine than hot cocoa.A standard 240 mL (8 oz) serving of a cola soft drink contains approximately 24-31 mg of caffeine. Cola is a popular flavor of soda around the world.Although the kola nut, from which the flavor of cola soda comes from, does naturally contain caffeine, the majority of the caffeine in cola is added by the manufacturer. Therefore, a cola soft drink would not be the best choice for a client looking to reduce their caffeine intake.
Choice C rationale:
Instant coffee contains even more caffeine.A standard 240 mL (8 oz) cup of instant coffee contains approximately 57-96 mg of caffeine.With instant coffee, caffeine measurements are based on the amount of the instant coffee powder used to make the drink. The caffeine content of coffee itself varies enormously.According to the USDA, 1 rounded teaspoon of instant coffee (1.8 grams in weight) contains 57 mg of caffeine.No matter how much water, milk, or creamer you add to the coffee - the amount of caffeine will remain the same. Therefore, instant coffee would not be a suitable choice for a client looking to reduce their caffeine intake.
Choice D rationale:
Brewed green tea also contains more caffeine than hot cocoa.An 8-ounce (240 mL) cup of green tea generally supplies around 20 to 45 milligrams of caffeine.This makes green tea a gentler alternative in terms of caffeine content, suitable for those who prefer a milder pick-me-up. However, it still contains more caffeine than hot cocoa. Therefore, while green tea is a healthier choice compared to cola soft drinks and instant coffee, it still contains more caffeine than hot cocoa.
Correct Answer is D
Explanation
Budesonide is a corticosteroid inhaler used for long-term management of asthma. It helps to reduce inflammation and prevent asthma symptoms. Rinsing the mouth and gargling with water after using a corticosteroid inhaler can help reduce the risk of developing oral thrush, a fungal infection.
The other statements are incorrect and indicate a misunderstanding of the teaching: "I will take my inhaler treatment before each meal and at bedtime": Budesonide is not typically used before meals or at bedtime. It is usually taken on a regular schedule, as prescribed by the healthcare provider, to provide long-term control of asthma symptoms.
Using the inhaler before exercising is important because physical activity can trigger asthma symptoms in some individuals. By using the inhaler before exercise, the client can help prevent exercise-induced asthma symptoms. However, this depends on the degree of difficulty of the exercise.
"I should use my inhaler when I have an asthma attack": Budesonide is not a rescue inhaler for immediate relief of asthma symptoms during an asthma attack. It is a controller medication meant to be used regularly to prevent symptoms from occurring
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