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 B
Explanation
A. Incorrect. The closure of the posterior fontanel by 23 months is a normal developmental milestone.
B. Correct. The anterior fontanel typically closes by 12 to 18 months of age. If it closes prematurely, it could be a sign of craniosynostosis and should be assessed by the provider.
C. Incorrect. Rolling from the back to the abdomen is a normal developmental milestone at around 46 months of age.
D. Incorrect. Moving objects to the mouth is a normal developmental behavior in infants as they explore their environment through sensory input.
Correct Answer is D
Explanation
A. The decision to place a loved one in long-term care is complex and should be made based on the family's needs and situation, not dictated by the nurse.
B. Suggesting the son find other family members for help is a reasonable idea, but it does not directly address his fatigue.
C. While taking care of a loved one is important, making the son feel obligated is not supportive or helpful.
D. Correct. Respite care provides temporary relief to caregivers and can help address the son's fatigue while ensuring his mother's needs are met.
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