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 postoperative and reports intermittent nausea
A client whose blood pressure is 160/90 mm Hg and reports a headache
A client who is scheduled for surgery in 2 hr
A client who is postoperative and has a Jackson-Pratt drain
The Correct Answer is B
Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.
While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.
The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.
The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.
B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.
C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.
D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
Correct Answer is A
Explanation
A.Using visual aids such as pictures, diagrams, or translation cards can help bridge the communication gap between the nurse and the client. This approach ensures better understanding and reduces miscommunication, especially when discussing procedures, medications, or discharge instructions.
B.This is not appropriate because family members may misinterpret medical information, omit details, or add their own opinions. A trained medical interpreter should be used to ensure accurate and confidential communication.
C. Speaking to the client at an increased volume in is not an effective solution for a language barrier. Simply speaking louder will not address the issue of language comprehension. It is important to use appropriate communication strategies, such as seeking a qualified interpreter or using visual aids or gestures to facilitate understanding.
D. Assuming that the client nodding indicates an understanding of the information in is not reliable. Nodding can have different cultural interpretations and may not always indicate comprehension. It is important to use other means of communication to confirm understanding, such as using a professional interpreter or utilizing visual aids.
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