a nurse is receiving change of shift report for a group of clients which of the following clients should the nurse plan to assess first

ATI LPN

ATI Comprehensive Predictor PN

1. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
C. A client who has epidural analgesia and weakness in the lower extremities.
D. A client who has a hip fracture and a new onset of tachypnea.

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

2. How should a healthcare professional assess a patient with dehydration?

A. Monitor skin turgor and check urine output
B. Assess for jugular venous distention
C. Auscultate lung sounds and monitor for fever
D. Monitor for cyanosis and increased respiratory rate

Correct answer: A

Rationale: Correct Answer: When assessing a patient for dehydration, healthcare professionals should monitor skin turgor, as it indicates the degree of dehydration, and check urine output, as decreased urine output can be a sign of dehydration. Choices B, C, and D are incorrect because they do not directly assess for dehydration. Assessing for jugular venous distention (B) is more relevant for heart failure, auscultating lung sounds and monitoring for fever (C) are more relevant for respiratory infections, and monitoring for cyanosis and increased respiratory rate (D) are more indicative of respiratory distress rather than dehydration.

3. A client with an NG tube is experiencing nausea and a decrease in gastric secretions. What should the nurse do first?

A. Position the client on their left side
B. Irrigate the NG tube with sterile water
C. Replace the NG tube with a new one
D. Increase the suction setting to relieve the blockage

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.

4. A client has hyperthermia. Which of the following actions should the nurse take?

A. Submerge the client's feet in ice water.
B. Cover the client with a thermal blanket.
C. Administer oral acetaminophen.
D. Initiate seizure precautions.

Correct answer: C

Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.

5. What are the complications of untreated deep vein thrombosis (DVT)?

A. Pulmonary embolism and stroke
B. Kidney failure and hypertension
C. Liver failure and electrolyte imbalance
D. Fluid overload and bradycardia

Correct answer: A

Rationale: Corrected Rationale: Untreated DVT can lead to complications such as pulmonary embolism and stroke. Pulmonary embolism occurs when a blood clot from the leg travels to the lungs, potentially blocking blood flow and causing respiratory distress. Stroke can occur if a blood clot dislodges from the leg veins, travels to the brain, and obstructs a blood vessel, leading to brain tissue damage. Both of these complications are life-threatening if not managed promptly. The other choices (B, C, D) do not represent common complications of untreated DVT and are therefore incorrect.