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 B

Explanation

Prednisone can cause blood glucose levels to increase.

The nurse should explain to the client that the reason for checking his blood glucose level is because prednisone, a medication he is receiving, can cause an increase in blood glucose levels. Prednisone is a corticosteroid medication that is commonly used in the treatment of various conditions, including COPD. It has the potential to raise blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and decreasing insulin sensitivity. Monitoring blood glucose levels is important to assess and manage any potential hyperglycaemia or changes in the client's blood sugar levels while on prednisone.

Older adults are not at increased risk for developing type 1 diabetes mellitus in (option A) is incorrect. Type 1 diabetes is an autoimmune condition that typically occurs in childhood or adolescence, and it is characterized by the destruction of insulin-producing cells in the pancreas.

Albuterol treatments, which are used to relieve bronchospasms in clients with COPD, are not known to cause blood glucose levels to decrease in (option C) is incorrect. Albuterol is a beta-2 adrenergic agonist that primarily acts on the respiratory system and does not have a direct effect on blood glucose levels.

Having COPD does not directly cause blood glucose levels to fluctuate in (option D) is incorrect. While there can be various factors that may indirectly affect blood glucose levels in individuals with COPD (e.g., medications, stress, comorbidities), the primary reason for monitoring blood glucose in this case is the use of prednisone.

In summary, the nurse should explain to the client that the blood glucose levels are being checked because prednisone, a medication he is taking for his COPD, can cause an increase in blood glucose levels. This allows for appropriate monitoring and management of any potential hyperglycemia associated with the use of prednisone.

A. We will keep the client's fluid intake restricted until he is free of pain. B. Expect the stoma to appear pale until healing is complete. C. We need to check the client's urine output every hour. D. Expect the diet’s urine to contain clots for the first 24 hours.

Correct Answer is C

Explanation

Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.

Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.

Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.

Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.

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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 assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with assistive personnel. Which of the following statements should the nurse include in the discussion?

Correct Answer is C

Explanation

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