a nurse is receiving change of shift report for a group of clients which of the following clients should the nurse plan to assess first

ATI LPN

ATI Comprehensive Predictor PN

1. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
C. A client who has epidural analgesia and weakness in the lower extremities.
D. A client who has a hip fracture and a new onset of tachypnea.

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

2. What are the key signs of infection after surgery?

A. Redness
B. Swelling
C. Fever
D. All of the above

Correct answer: D

Rationale: After surgery, key signs of infection include redness, swelling, and fever. Redness and swelling can indicate inflammation at the surgical site, while fever is a systemic response to infection. Choosing 'All of the above' (Option D) is the correct answer because all three signs are commonly associated with post-surgical infections. Options A, B, and C are incorrect as each of them individually can be a sign of infection, but considering all three together provides a more comprehensive assessment for post-operative infection.

3. What are the steps in managing a patient with a pressure ulcer?

A. Clean the wound and apply a hydrocolloid dressing
B. Debride necrotic tissue and apply antibiotics
C. Apply an alginate dressing and elevate the affected area
D. Use moisture-retentive dressings and reposition frequently

Correct answer: A

Rationale: The correct answer is A: Clean the wound and apply a hydrocolloid dressing. This step is crucial in managing a pressure ulcer as it helps protect the ulcer from infection and promotes healing by creating a moist environment conducive to tissue repair. Choice B, debriding necrotic tissue and applying antibiotics, is more suitable for managing infected pressure ulcers but not as the initial step. Choice C, applying an alginate dressing and elevating the affected area, may be part of the management but is not the initial step. Choice D, using moisture-retentive dressings and repositioning frequently, is important for prevention but not the first step in managing an existing pressure ulcer.

4. How should a healthcare professional respond to a patient with diabetic ketoacidosis (DKA)?

A. Administer insulin
B. Administer IV fluids
C. Monitor blood glucose
D. All of the above

Correct answer: D

Rationale: When managing a patient with diabetic ketoacidosis (DKA), it is crucial to administer insulin to lower blood sugar levels, administer IV fluids to correct dehydration and electrolyte imbalances, and monitor blood glucose levels regularly to ensure they are within the target range. Therefore, all of the above options are essential components of the comprehensive treatment plan for DKA. Administering insulin alone may lower blood sugar levels but will not address the fluid and electrolyte imbalances seen in DKA. Similarly, administering IV fluids alone may help with dehydration but will not address the high blood sugar levels or the need for insulin. Monitoring blood glucose alone is not sufficient to treat DKA; it must be accompanied by appropriate interventions to address the underlying causes and complications of the condition.

5. A client at 20 weeks of gestation is being taught by a nurse about an alpha-fetoprotein (AFP) test. Which of the following information should the nurse include?

A. This test is used to confirm pregnancy
B. This test is used to detect neural tube defects
C. This test will determine the baby's lung maturity
D. This test will check for gestational diabetes

Correct answer: B

Rationale: The correct answer is B: 'This test is used to detect neural tube defects.' An alpha-fetoprotein test is essential for screening neural tube defects in the fetus, not for confirming pregnancy, determining lung maturity, or checking for gestational diabetes. Detecting neural tube defects is crucial for early intervention and management of potential health issues in the baby.