a nurse has just received change of shift report for four clients which of the following clients should the nurse assess first 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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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. When the nurse receives a shift report from the nurse going off shift and asks about a patient's state of mind and emotional needs, which aspect of Dr. Watson's theory is demonstrated?

Correct answer: C

Rationale: The correct answer is C: Caritas. The act of inquiring about a patient's state of mind and emotional needs reflects the concept of Caritas in Dr. Watson's theory. Caritas involves showing deep concern, compassion, and love for the patient, going beyond just the physical aspects of care. Choice A, Intentionality, refers to the capacity for nurses to act deliberately with an ultimate goal in mind. Choice B, Curiosity, is not directly related to the specific action described in the question. Choice D, Holism, involves considering the patient as a whole being, including physical, emotional, social, and spiritual aspects, but it is not specifically demonstrated by inquiring about emotional needs and state of mind.

3. During a home visit, the nurse should evaluate the adequacy of a client's COPD treatment by assessing for which primary symptom?

Correct answer: A

Rationale: Assessing for dyspnea is crucial when evaluating COPD treatment effectiveness as it is a primary symptom of the condition. Dyspnea, or difficulty breathing, is a common and distressing symptom in COPD patients. Monitoring the severity of dyspnea can provide valuable insights into the client's response to treatment and disease progression.

4. The healthcare provider is caring for an adolescent who will be hospitalized for several weeks while in traction. The patient frequently has a room full of friends, and they can be heard laughing. The healthcare provider recognizes this patient is meeting which of Maslow's hierarchy of needs?

Correct answer: B

Rationale: Love and belonging needs, as per Maslow's hierarchy, refer to the sense of belonging, being accepted, and forming meaningful relationships. In this scenario, the patient having friends around and engaging in social interactions indicates fulfillment of the love and belonging need. Choice A, self-esteem, focuses on self-respect and confidence, which are not directly related to the patient's interaction with friends. Choice C, safety, involves physical and psychological safety, which may be important but not the primary need being met in this situation. Choice D, self-actualization, relates to realizing personal potential, creativity, and achieving goals, which are at a higher level in the hierarchy compared to the need for love and belonging.

5. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40 mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following findings indicates she is dehydrated?

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity greater than 1.030 is indicative of dehydration as it reflects concentrated urine. Choice A is incorrect as a specific gravity of 1.020 is within the normal range. Choice C, decreased skin turgor, can be a sign of dehydration but is not as specific as urine specific gravity. Choice D, decreased heart rate, is not typically a direct indicator of dehydration.

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