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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?
- A. A client who is scheduled for surgery in 2 hr
- B. A client whose blood pressure is 160/90 mm Hg and reports a headache
- C. A client who is postoperative and reports intermittent nausea
- D. A client who is postoperative and has a Jackson Pratt drain
Correct Answer: B
Rationale: Elevated blood pressure with a headache suggests a hypertensive crisis, requiring immediate assessment to prevent complications like stroke. Other conditions are less urgent.
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A nurse is assisting with the care of a client who is at 38 weeks of gestation and in active labor. Which of the following actions should the nurse take?
- A. Apply counterpressure to the client's sacrum during contractions.
- B. Position the client in a supine position during contractions.
- C. Encourage the client to take deep, cleansing breaths between contractions.
- D. Administer oxygen at 2 L/min via nasal cannula during contractions.
Correct Answer: C
Rationale: Deep breaths between contractions promote relaxation and oxygenation. Counterpressure may help some, supine position risks vena cava compression, and oxygen isn't routinely needed.
A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
- A. I can remove my security band to give it to a family member.
- B. I will carry my baby to the nursery.
- C. I will have an identification band that matches the one my baby wears.
- D. I can take my baby to the lobby to visit family.
Correct Answer: C
Rationale: Matching identification bands ensure mother and baby are correctly paired, a key security measure. Removing bands, carrying to the nursery, or taking the baby to public areas risks safety.
A nurse is reinforcing teaching with a client who has a new prescription for tramadol. Which of the following instructions should the nurse include?
- A. Take this medication with food to prevent nausea.
- B. You might experience constipation while taking this medication.
- C. You should avoid driving until you know how this medication affects you.
- D. You can increase the dose if your pain persists.
Correct Answer: B,C
Rationale: Tramadol can cause constipation, and its sedative effects warrant avoiding driving initially. Food may help nausea but isn't required, and dose increases need provider approval.
A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.5°C (101.3°F).
- C. The client has not voided in 6 hr.
- D. The client's lochia is moderate.
Correct Answer: B
Rationale: A temperature of 38.5°C suggests infection, requiring reporting. Pain, delayed voiding, and moderate lochia are expected or less urgent.
A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports shoulder pain.
- B. The client's temperature is 38.2°C (100.8°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with slight redness.
Correct Answer: B
Rationale: A temperature of 38.2°C suggests infection, requiring reporting. Shoulder pain is referred pain, no bowel movement is expected, and slight redness is normal.