a nurse is a receiving report on four clients which of the following clients should the nurse assess first
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?

Correct answer: C

Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.

2. A healthcare professional is assessing a client for signs of anaphylaxis. Which of the following findings should the healthcare professional look for?

Correct answer: B

Rationale: Hypotension is a critical sign of anaphylaxis. During anaphylaxis, there is a widespread vasodilation leading to a drop in blood pressure, which manifests as hypotension. This can be accompanied by other symptoms such as swelling, difficulty breathing, hives, and itching. Bradycardia (choice A) is not typically associated with anaphylaxis; instead, tachycardia is more common due to the body's response to the allergic reaction. Increased appetite (choice C) is unrelated to anaphylaxis, as individuals experiencing anaphylaxis often feel unwell and may have nausea or vomiting. Decreased respiratory rate (choice D) is also not a typical finding in anaphylaxis; instead, respiratory distress and wheezing are more commonly observed.

3. A client has been prescribed ferrous sulfate. Which instruction should the nurse include?

Correct answer: B

Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with a glass of orange juice. Vitamin C, found in orange juice, enhances the absorption of iron, making it more effective. Taking ferrous sulfate with meals, at bedtime, or with milk can decrease its absorption and effectiveness, so these options are incorrect.

4. A nurse is providing teaching for a client who has GERD. Which of the following assessment findings should the nurse expect to find?

Correct answer: C

Rationale: The correct answer is C: Atypical chest pain. GERD often presents with atypical chest pain due to acid reflux, which can mimic the symptoms of cardiac conditions but is related to the esophagus. Shortness of breath (choice A) is not a typical assessment finding in GERD. Rebound tenderness (choice B) is associated with peritoneal inflammation, not GERD. Vomiting blood (choice D) is a severe symptom that may indicate esophageal damage but is not a common assessment finding in GERD.

5. A client who is at 32 weeks gestation and has a history of cardiac disease is being cared for by a nurse. Which of the following positions should the nurse place the client in to best promote optimal cardiac output?

Correct answer: D

Rationale: The correct answer is the left lateral position. Placing the client in the left lateral position promotes optimal cardiac output during pregnancy by reducing pressure on the inferior vena cava, improving blood flow to the heart and fetus. Choice A, 'The chest,' is incorrect as it does not describe a position that benefits cardiac output. Choice B, 'Standing,' is incorrect as it does not alleviate pressure on the vena cava. Choice C, 'Supine,' is contraindicated in pregnancy, especially in clients with cardiac disease, as it can compress the vena cava and decrease cardiac output.

Similar Questions

While caring for a client receiving oxytocin for labor augmentation, the nurse notes contractions occurring every 45 seconds and lasting 90 seconds. What should the nurse do?
A charge nurse is discussing HIPAA with a newly licensed nurse. Which action should the charge nurse include in the teaching as an example of a HIPAA violation?
A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?
A client who is Rh-negative is being taught about Rh (D) immune globulin by a nurse. Which statement by the client indicates an understanding of the teaching?
A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses