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","C","E"]
Explanation
B: A repeat Mantoux test is commonly performed to monitor the effectiveness of tuberculosis treatment. It's important for the client to understand the need for follow-up testing.
C: Interactions between tuberculosis medications and other medications can occur. The client's understanding of the importance of notifying the provider about new medications helps ensure their safety and treatment effectiveness.
E: Tuberculosis treatment typically involves a combination of medications taken for a specific duration. Understanding the duration of treatment is important for the client's compliance and successful outcome.
Correct Answer is C
Explanation
A. Incorrect. A urine output of 300 ml over 8 hours is within the expected range for a postoperative client and does not require immediate reporting.
B. Incorrect. Occasional small clots in the urine are common in the immediate postoperative period following a transurethral resection of the prostate and do not necessarily require immediate reporting.
C. Correct. Dark red urine can indicate bleeding and may be a sign of hemorrhage. This finding should be reported to the provider for further assessment and intervention.
D. Incorrect. A frequent urge to urinate is expected following a transurethral resection of the prostate, as irritation and swelling can occur in the immediate postoperative period.
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