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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Correct.

Option A, reminding the client of the day and time often, aligns with this goal. Orienting the individual to time and place can help reduce confusion and disorientation commonly associated with delirium.
B. Incorrect. Offering the client several choices at mealtimes, might not directly address the issue of orientation and may potentially overwhelm the individual, exacerbating their confusion.

C. Incorrect. Discussing the client's fears and addressing their concerns is important for providing appropriate care and support.
D. Incorrect. Alternating daily caregivers may increase confusion for the client experiencing delirium. Consistency in care providers can be beneficial.

A. Increase dietary potassium. B. Withhold the medication if the pulse rate is less than 60/min. C. Decrease daily fluid intake. D. Rise slowly from a sitting position to a standing position.

Correct Answer is D

Explanation

A. Incorrect. While monitoring dietary potassium might be relevant for some clients on certain medications, it is not the primary action for addressing syncope related to enalapril.
B. Incorrect. Withholding the medication based solely on pulse rate is not an appropriate action.
The nurse should provide guidance on appropriate management.
C. Incorrect. Decreasing daily fluid intake is not likely to address the syncope related to enalapril.
D. Correct. Enalapril is an ACE inhibitor, and syncope can be a side effect due to changes in blood pressure. Advising the client to rise slowly from a sitting position can help prevent sudden drops in blood pressure and decrease the risk of syncope.

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A nurse on a medical surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is A

Explanation

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

Correct Answer is D

Explanation

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