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

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. An example of government nutrition policy is:

Correct answer: C

Rationale: The correct answer is C: Healthy People 2020. Healthy People 2020 is a government initiative that sets goals for improving the health of Americans, including specific nutritional objectives. Choices A, B, and D are not examples of government nutrition policies. MyPlate Food Guidance System is a visual tool to help individuals make healthy food choices, Dietary Guidelines for Americans 2010 provide evidence-based advice for Americans two years and older, and Dietary Reference Intakes (DRIs) are a set of nutrient reference values.

3. A client is to receive oxytocin to augment labor. Which finding contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

Correct answer: A

Rationale: Late decelerations are indicative of uteroplacental insufficiency, which can be exacerbated by oxytocin administration, potentially compromising fetal well-being. Therefore, detecting late decelerations should prompt immediate reporting to the provider to prevent harm to the fetus. Choices B, C, and D are not contraindications for initiating oxytocin infusion. Moderate variability of the FHR is a reassuring sign of fetal well-being, cessation of uterine dilation may indicate a pause in labor progress but does not contraindicate oxytocin, and prolonged active phase of labor may necessitate oxytocin administration to augment contractions and progress labor.

4. A gerontological nurse is conducting an in-service program for a group of nurses who work with a wide range of culturally diverse older adults. After teaching the group about the impact of culture on health and illness, the nurse determines that the teaching was successful when the group identifies which reason as underlying the need to understand culture?

Correct answer: B

Rationale: The correct answer is B because understanding the impact of culture on health and illness enables nurses to provide individualized and culturally sensitive care to older adults from diverse backgrounds. This approach ensures that the cultural, religious, and sexual orientation differences of older adults are acknowledged, respected, and factored into their care. Choice A is not as comprehensive as B, as the goal goes beyond just respecting customary practices. Choice C, while important, is more focused on medical treatments rather than holistic care. Choice D is not the primary reason for understanding culture; the main goal is to provide personalized care that respects individual differences.

5. A client has a new prescription for metformin. Which of the following statements should the nurse include in the teaching?

Correct answer: C

Rationale: Increasing fluid intake is an important teaching point for clients starting metformin to prevent gastrointestinal discomfort, a common side effect of this medication. Metformin can cause gastrointestinal symptoms such as nausea, bloating, and diarrhea, which can be reduced by staying well-hydrated. Therefore, advising the client to increase their fluid intake will help minimize these side effects and improve medication tolerance. The other options are incorrect: Option A is a general instruction for taking medications but not specifically related to metformin. Option B is incorrect because metformin typically does not cause hypoglycemia but rather hyperglycemia. Option D is also incorrect as a metallic taste in the mouth is not a common side effect of metformin.

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