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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma.The opening on the skin barrier should be cut to fit closely around the stoma, approximately 0.3-0.6 cm (1/8 to 1/4 inch) larger than the stoma size. A larger opening (like 0.5 inches) could expose too much surrounding skin, increasing the risk of skin irritation from contact with the stoma's effluent.
B. Use a moisturizing soap to clean the skin around the client's stoma.Moisturizing soaps should be avoided because they can leave a residue on the skin, which may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with mild soap and water, or water alone, and then dried thoroughly before applying the new appliance.
C. Empty the client's ostomy pouch before removing the skin barrier.Emptying the ostomy pouch before removing the skin barrier is a practical step to reduce spillage of stool during the appliance change, making the process cleaner and easier to manage. It also minimizes the risk of contamination of the surrounding area or wound.
D. Change the client's ostomy appliance 1 hour after breakfast.Ostomy appliances are best changed when the bowel is least active, which is usually before a meal or several hours after eating. Changing the appliance shortly after a meal, such as 1 hour after breakfast, may result in more stoma output, making it harder to manage the appliance change.
Correct Answer is C
Explanation
Choice A: While nitroglycerin is a common medication for angina, calling the provider after just one dose is not the recommended action. Nitroglycerin helps relax coronary arteries and improve blood supply to the heart. However, if chest pain persists, the client should follow additional steps..
Choice B: This describes the Valsalva maneuver, which involves holding the breath and bearing down as though straining to initiate a bowel movement. While this technique can regulate heart rhythms and help the ears to pop, it is not the recommended response to chest pain from angina.
Choice C: Correct: This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.
Choice D: Aspirin can be beneficial during angina episodes. However, the recommended dose is usually 162 to 325 milligrams (one tablet). Taking two tablets at once may not be necessary unless specifically advised by a healthcare provider.
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