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 B

Explanation

The occiput refers to the back of the head. Placing a small pillow or padding under the occiput can help relieve pressure and provide support to the client's head and neck when they are placed in the supine position.

Breasts: When in the prone position, breasts may be compressed or flattened. To relieve pressure, it may be necessary to use positioning techniques that distribute weight evenly and avoid direct pressure on the breasts, such as using cushions or foam pads to support the chest and torso.

Heels: The heels are prone to pressure ulcers when a client is lying in the supine position for extended periods. To relieve pressure, it is important to use proper heel offloading techniques, such as placing heel protectors or pillows under the lower legs to elevate the heels off the bed surface and prevent direct pressure.

Coccyx: The coccyx is the tailbone region at the base of the spine. When in the supine position, pressure on the coccyx can be relieved by using a cushion or padding under the pelvic area, specifically under the bony prominence of the coccyx, to reduce direct pressure and provide comfort.

A. Baked chicken breast B. Orange juice C. Sweet potato D. Cantaloupe

Correct Answer is A

Explanation

A. Correct. Baked chicken breast is relatively low in potassium compared to the other options.
B. Incorrect. Orange juice is high in potassium.
C. Incorrect. Sweet potatoes are high in potassium.
D. Incorrect. Cantaloupe is moderately high in potassium.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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