A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?
Explanation & Rationale
A. A client who is postoperative and has a Jackson-Pratt drain. A Jackson-Pratt drain is a routine postoperative device used to prevent fluid accumulation. Unless there are signs of excessive drainage, infection, or blockage, this client does not require immediate attention. B. A client who is scheduled for surgery in 2 hr. While preoperative preparation is important, it is not the most urgent concern. This client can be attended to after addressing more pressing clinical issues, such as potential hypertensive complications. C. A client whose blood pressure is 160/90 mm Hg and reports a headache. A significantly elevated blood pressure with a headache may indicate a hypertensive crisis, which increases the risk of stroke or other complications. This client should be assessed immediately to determine the severity and need for intervention. D. A client who is postoperative and reports intermittent nausea. Nausea is a common postoperative symptom and can often be managed with antiemetics and dietary modifications. It does not pose an immediate life-threatening risk compared to possible hypertensive emergencies.