a nurse on the medical surgical unit is receiving reports on four clients which of the following clients should the nurse assess first
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse on the medical-surgical unit is receiving reports on four clients. Which of the following clients should the nurse assess first?

Correct answer: D

Rationale: The client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat should be assessed first. This client may be experiencing airway obstruction due to hematoma or swelling, making it a priority. Options A, B, and C have concerning findings as well, but airway compromise takes precedence over other issues.

2. While documenting client care, which of the following entries should the nurse identify as an example of implementing client care?

Correct answer: B

Rationale: Administering medications as prescribed is a clear example of implementing client care because it involves carrying out a specific aspect of the care plan. Contacting the provider to report client findings is more related to assessment and communication. Reviewing the client's lab results is part of assessment and data collection. Discussing the care plan with the family is focused on collaboration and planning, rather than direct implementation.

3. A nurse is reviewing the laboratory results for a client who has a prescription for filgrastim. The nurse should recognize that an increase in which of the following values indicates a therapeutic effect of this medication?

Correct answer: B

Rationale: Filgrastim is used to increase neutrophil production in clients undergoing chemotherapy or with bone marrow suppression. A rise in neutrophil count indicates the medication is working effectively to boost immune response. Choices A, C, and D are incorrect as filgrastim primarily targets neutrophils, not erythrocytes, lymphocytes, or thrombocytes.

4. A client expresses anxiety about an upcoming surgery. What should the nurse do?

Correct answer: B

Rationale: Asking the client to describe their feelings is the most appropriate action for the nurse to take. This allows the nurse to understand the specific concerns and anxieties the client is experiencing. Choice A may invalidate the client's feelings and not address the root cause of anxiety. Choice C may come across as dismissive and oversimplified. While providing information about the surgery (Choice D) is important, addressing the client's emotional state is the initial priority in this situation.

5. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

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