a nurse is receiving a change of shift report on a group of clients which of the following patients should the nurse assess first a nurse is receiving a change of shift report on a group of clients which of the following patients should the nurse assess first
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?

Correct answer: A

Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.

2. Protein is constantly being exchanged between which two components?

Correct answer: A

Rationale: The correct answer is 'tissue and plasma.' Protein turnover involves the continuous exchange of proteins between body tissues and the bloodstream (plasma) as part of normal metabolic processes. This process ensures a balance in protein levels throughout the body. Choices B, C, and D are incorrect as they do not represent the primary sites for protein turnover in the body.

3. A client with pancreatitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Decreasing the intake of high-fat foods is essential in managing pancreatitis as high-fat foods can exacerbate symptoms and lead to complications. By reducing high-fat foods in their diet, the client demonstrates an understanding of the dietary management needed for pancreatitis. Choices A, C, and D are incorrect. Increasing high-fat foods (Choice A) is not recommended for pancreatitis as it can worsen the condition. While high-protein foods (Choice C) can be beneficial in some cases, the primary focus in pancreatitis management is on reducing fat intake. Decreasing high-protein foods (Choice D) is not a key dietary management approach for pancreatitis.

4. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

Correct answer: A

Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.

5. Which nutrient is known to reduce the risk of neural tube defects when taken by pregnant women?

Correct answer: C

Rationale: Folic acid, a B vitamin, is essential for the development of the neural tube in the early stages of pregnancy. Adequate intake of folic acid before conception and during early pregnancy significantly reduces the risk of neural tube defects in the baby. It is recommended that women of childbearing age consume folic acid daily to support a healthy pregnancy.

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