a nurse is caring for four clients which client should the nurse assess first
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is caring for four clients. Which client should the nurse assess first?

Correct answer: C

Rationale: The correct answer is C. The client with hypothyroidism who is stuporous should be assessed first as this may indicate a critical condition, possibly related to severe hypothyroidism. Stupor is a state of near-unconsciousness or insensibility, suggesting a decline in neurological function that requires immediate evaluation. Choices A, B, and D do not present with immediate life-threatening conditions that require urgent assessment. While chemotherapy, post-appendectomy complications, and burn care are important, they do not pose the same level of immediate risk as a stuporous client.

2. A nurse is caring for a client with a new prescription for clindamycin. Which of the following should the nurse monitor?

Correct answer: C

Rationale: The correct answer is C: Signs of superinfection. Clindamycin can lead to antibiotic-associated colitis and other superinfections, making it crucial for the nurse to monitor the client for signs of superinfection. Monitoring liver function (choice A) is not typically associated with clindamycin use. Serum potassium levels (choice B) and blood glucose (choice D) are also not directly affected by clindamycin, so they are not the priority for monitoring in this case.

3. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?

Correct answer: B

Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.

4. A nurse is assessing a client with pancreatitis. Which of the following findings should the nurse look for?

Correct answer: B

Rationale: The correct answer is B: Abdominal pain. Abdominal pain, often severe, is a hallmark sign of pancreatitis. Other common symptoms include nausea, vomiting, and tenderness in the abdomen. Choices A, C, and D are incorrect because increased appetite, weight gain, and elevated blood pressure are not typically associated with pancreatitis. Therefore, the nurse should primarily focus on assessing for abdominal pain in a client with suspected pancreatitis.

5. A nurse is preparing to administer a dose of iron supplement. Which of the following should the nurse do?

Correct answer: B

Rationale: The correct answer is B: Administer it on an empty stomach. Iron supplements are best absorbed on an empty stomach to enhance their absorption. It is important to avoid giving them with milk or dairy products as these can inhibit iron absorption. Checking blood pressure and monitoring for allergic reactions are not directly related to the administration of iron supplements and are not the primary considerations in this case.

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When planning to discharge a client receiving home oxygen therapy, which of the following instructions should the nurse include in the discharge teaching?

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