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

Correct. Pelvic rocking exercises can help alleviate lower back pain during pregnancy by promoting movement and flexibility in the pelvic area.

Picking up heavy items with the arms might not directly address lower back pain during pregnancy.

Sitting in a hot tub for extended periods is not recommended during pregnancy due to the risk of overheating.

Raising chairs to keep knees lower than hips is a general ergonomic recommendation, but it might not directly address lower back pain.

A. Heart rate B. Pain C. Cold, clammy skin D. Mental confusion E. Respiratory status F. Blood pressure G. Urine output H. Temperature I. Sodium level

Correct Answer is ["A","C","D","F","G","H"]

Explanation

A.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

B.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

D.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

E.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

F.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

G.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

H.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

I.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

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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

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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?