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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While the client's health insurance status is important for financial considerations, it might not be relevant to the interprofessional team meeting.
B. The timing of the client's dressing change and vital signs are specific care details that may not be essential for the interprofessional team.
D. Correct. The client's difficulty ambulating is a significant change in their condition that may impact care decisions and require input from the interprofessional team.
Correct Answer is C
Explanation
A. Incorrect. Countertransference refers to the nurse's emotional reaction to the client based on the nurse's personal feelings or past experiences.
B. Incorrect. Boundary crossing refers to the nurse's actions that blur the professional boundaries of the nurse-client relationship, and this action does not necessarily represent boundary-crossing.
C. Correct. The nurse's action of interrupting the bath to obtain a healthy meal for the client demonstrates an immediate response to the client's need and promotes trust and rapport between the nurse and the client.
D. Incorrect. Veracity refers to truthfulness and honesty, but it does not directly apply to the nurse obtaining a meal for the client who is hungry.
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