a nurse is assessing a client for signs of infection which of the following findings should the nurse look for
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

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

Correct answer: B

Rationale: Corrected Question: A healthcare professional is assessing a client for signs of infection. The correct answer is 'Fever.' Fever is a common sign of infection and indicates an immune response to an invading pathogen. Increased energy (Choice A) is not typically associated with infection, as the body often feels fatigued when fighting an infection. Improved appetite (Choice C) and stable weight (Choice D) are not specific signs of infection and may not necessarily indicate the presence of an infectious process. Therefore, the healthcare professional should focus on monitoring for fever as a key indicator of infection.

2. 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.

3. A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?

Correct answer: A

Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.

4. A client has a new prescription for oxcarbazepine. Which of the following should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Serum sodium levels. Oxcarbazepine can lead to hyponatremia, making it crucial to monitor serum sodium levels. Monitoring liver function (choice A) is not typically associated with oxcarbazepine use. Blood glucose (choice C) monitoring is more relevant in medications affecting blood sugar levels. Heart rate (choice D) is not directly impacted by oxcarbazepine.

5. A nurse is assessing a client with chronic kidney disease. Which of the following should the nurse monitor for?

Correct answer: A

Rationale: The correct answer is A: Hyperkalemia. Clients with chronic kidney disease are at risk for hyperkalemia due to impaired potassium excretion. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to its accumulation in the blood. Hypercalcemia (Choice B) is not typically associated with chronic kidney disease. Hypoglycemia (Choice C) refers to low blood sugar levels and is not directly related to chronic kidney disease. Hyponatremia (Choice D) is a condition characterized by low sodium levels and is not a typical concern in chronic kidney disease.

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