A nurse is caring for four clients. Which one would the nurse see first?
Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg.
Hypertensive client with a blood pressure of 156/90 mm Hg.
Client who needs pain medication prior to a dressing change of a surgical wound.
Client who had a first dose of captopril and needs to use the bathroom.
The Correct Answer is A
A. A client with low blood pressure (98/58 mm Hg) who requires a beta blocker should be seen first because beta blockers can lower blood pressure further, possibly leading to hypotension or dizziness.
B. A hypertensive client with a blood pressure of 156/90 mm Hg is stable and does not require immediate intervention.
C. While pain medication is important, it is not as urgent as addressing a client with low blood pressure and a medication that can worsen the condition.
D. The client who just had captopril can wait to use the bathroom, as the priority is addressing their blood pressure and captopril's effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing respiratory status is the priority in heart failure exacerbation, as respiratory distress can rapidly worsen and affect oxygenation.
B. While knowing current medications is important, the priority in this situation is addressing the client's respiratory needs.
C. Administering furosemide is part of the management plan but should follow the initial assessment of the client's condition, especially respiratory status.
D. Drawing blood is helpful but not the immediate priority in managing acute heart failure exacerbation.
Correct Answer is C
Explanation
A. Serum insulin levels reflects short-term insulin secretion but does not indicate long-term glucose control.
B. Hemoglobin levels relate to anemia, not glucose control.
C. Hemoglobin A1C level reflects the average blood glucose over the past 2-3 months, providing an excellent measure of long-term control.
D. Fingerstick fasting blood glucose level reflects glucose levels at the moment of testing, not long-term control.
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