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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.

B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.

C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.

D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.

A. Insert a foley catheter. B. Schedule a pelvic magnetic resonance imaging test. C. Infuse normal saline at 50 ml/hr. D. Draw blood for a complete blood count.

Correct Answer is A

Explanation

A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.

B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.

C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.

D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for four clients. Which one would the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?

Correct Answer is A

Explanation

A client who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

Correct Answer is A

Explanation

A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes a distended abdomen with absent bowel sounds in all quadrants. To maintain adequate nutrition, the nurse should plan to take which action?

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Which assessment finding in a 36-year-old client is most indicative for further evaluation?

A client has been placed on a mechanical ventilator. The PCP has ordered the ventilator to be set at a respiratory rate of 28 breaths /min. The nurse questions the order, citing concerns about which acid-base problem?

A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority?

The nurse in the women's health clinic has four clients who are waiting to be seen. Which client should the nurse see first?

A client is in the hospital and has received two doses of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below. What action by the nurse is most appropriate?

A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the client is identified as "George Smith." The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?