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
A. Correct. Montelukast is typically given once daily in the evening to manage asthma symptoms.
B. Montelukast is not a replacement for inhaled steroids. The parent should not stop the medication without consulting the healthcare provider.
C. Montelukast is not used for acute wheezing; it is a maintenance medication and not for immediate relief.
D. Montelukast can start to show benefits within a few days of starting, not necessarily 2 months.
Correct Answer is A
Explanation
A. Correct. Assessing whether the client has a plan for self-harm is a priority in evaluating the immediate risk of suicide. If a plan is present, further assessment and intervention are needed.
B. Incorrect. While having support is important, knowing whether the client has a plan for self-harm takes precedence.
C. Incorrect. While a family history of suicide is a risk factor, it is not as immediate a concern as determining whether the client has a current plan.
D. Incorrect. Assessing the sources of stress is important, but the immediate risk of self-harm takes priority.
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