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

Answer and Explanation

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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Correct Answer is A

Explanation

Promoting trust involves actions that build a sense of trust and rapport between the nurse and the client. In this scenario, the nurse recognizes the client's basic need for food and responds to it promptly and compassionately. By interrupting the bath to address the client's hunger, the nurse demonstrates attentiveness and care, which helps establish trust between the nurse and the client.

Countertransference refers to the nurse's emotional reaction or response to the client, which may be based on the nurse's personal experiences or unresolved issues. It does not apply to the nurse's action of obtaining a meal for the client.

Veracity refers to truthfulness and honesty. While the nurse's action can be seen as honest and caring, it does not specifically relate to the concept of veracity.

Boundary crossing refers to a situation where the nurse exceeds the established professional boundaries with the client. In this scenario, the nurse's action of obtaining a meal for the client can be seen as a minor deviation from the routine care but is not considered a significant boundary crossing.

A. Location of the identification tag on the client's body B. Copy of the client's advance directives C. Cause of the client's death D. Last set of the client's vital signs

Correct Answer is A

Explanation

Correct answer: A

A.It is important to document the location of the identification tag to ensure proper identification of the body. This is crucial for legal and administrative purposes and helps prevent any potential confusion or misidentification.

B.A copy of the client's advance directivesis an important document for healthcare providers to have during the client's care but is not typically included in the post-mortem documentation. Advance directives are typically stored separately and are more relevant to the client's care while they are alive.

C. Cause of the client's death: Determining and documenting the cause of death is typically the responsibility of the attending physician or medical examiner, not the nurse.

D.The last set of the client's vital signs in (option D) may be relevant during the client's care and treatment but may not be specifically included in the post-mortem documentation. The focus of post-mortem documentation is usually on aspects such as the cause of death, time of death, interventions performed, and any significant findings related to the client's condition or autopsy.

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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 A

Explanation

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Correct Answer is A

Explanation

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