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 {"dropdown-group-1":"D","dropdown-group-1":"B"}

Explanation

The nurse should first anticipate the need to withhold oral intake then assess the client's vital signs.

Given the client’s symptoms of gnawing abdominal pain, dark tarry stools (indicating possible gastrointestinal bleeding), and pain worsened by eating, withholding oral intake is crucial to prevent further irritation or complications, especially before an endoscopic procedure. This helps avoid complications such as aspiration or exacerbating gastrointestinal issues. After ensuring that oral intake is managed appropriately, the nurse should then assess the client's vital signs to monitor for signs of hemodynamic instability or further deterioration, which can provide critical information about the client's current condition and guide further interventions.

A. "I should leave my steris-trips on until they fall off." B. "I should eat a high-fat diet for several weeks." C. "I should expect to have diarrhea until my diet changes." D. "I should expect to have nausea for several days."

Correct Answer is A

Explanation

A. Correct. Leaving steris-trips on until they fall off naturally promotes wound healing and reduces the risk of infection.
B. Incorrect. A high-fat diet is not recommended post-cholecystectomy; a low-fat diet is usually advised to prevent discomfort.
C. Incorrect. Diarrhea is not a common or expected outcome following laparoscopic cholecystectomy.
D. Incorrect. While some postoperative nausea might be expected, it should not persist for several days. Prolonged nausea may require medical attention.

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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

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options. The nurse should first anticipate the need to dropdown then dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-1":"B"}

Explanation

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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