a nurse has just received change of shift report for four clients which of the following clients should the nurse assess first
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ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

2. A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity?

Correct answer: B

Rationale: The correct action to verify a client's identity when administering medications is to scan the client's facility identification band. This method ensures accuracy and helps prevent medication errors. Asking the client's full name (Choice A) may not be reliable as names can be similar, leading to confusion. Calling the client's name (Choice C) may not be effective if there are multiple clients with the same name in the facility. Verifying with a second nurse (Choice D) is an important safety measure for certain tasks but is not specifically for verifying a client's identity.

3. When providing discharge teaching to a client with diabetes, what is the most important instruction?

Correct answer: B

Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.

4. A nurse is caring for a client who is in the early stages of hypovolemic shock. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.

5. How can a healthcare professional reduce the risk of falls in elderly patients?

Correct answer: D

Rationale: All of these interventions are crucial in reducing the risk of falls in elderly patients. Encouraging the use of assistive devices helps provide support and stability, clearing walkways minimizes tripping hazards, and ensuring proper lighting enhances visibility and reduces the chances of falls. Therefore, choosing 'All of the above' is the most appropriate answer as each intervention plays a significant role in fall prevention.

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