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 A

Explanation

A. Correct. For a client with a pre-pregnancy BMI of 30.5 (considered obese., an acceptable weight gain during pregnancy is typically around 1120 pounds (59 kg., making 16 pounds an appropriate option within this range.
B. Incorrect. A weight gain of 32 pounds would be considered excessive for a client with a pre-pregnancy BMI of 30.5.
C. Incorrect. A weight gain of 24 pounds might still fall within an acceptable range, but for a client with a pre-pregnancy BMI of 30.5, a weight gain of 16 pounds is a more appropriate option.
D. Incorrect. A weight gain of 8 pounds would likely be insufficient for a client with a pre-pregnancy BMI of 30.5.

A. Place the client in a supine position. B. Ensure the device is kept below the level of the client's chest. C. Empty the collection chamber every 8 hr. D. Clamp the chest tube every 4 hr.

Correct Answer is B

Explanation

A. Incorrect. Placing the client in a supine position may impede drainage and is not recommended for a client with a chest tube.
B. Correct. Ensuring that the chest tube drainage system is kept below the level of the client's chest allows for proper drainage of fluid and prevents backflow of drainage into the client's chest.
C. Incorrect. The collection chamber should be emptied as needed to prevent overfilling, which could obstruct drainage.
D. Incorrect. Clamping the chest tube is not indicated for a client with a chest tube set to continuous suction, as it would interfere with the function of the drainage system.

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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

A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should include which of the following is an acceptable weight gain for this client?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Correct Answer is B

Explanation

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