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

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

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

Correct answer: D

Rationale: The correct answer is D because a client with a fractured femur and sudden chest pain may be experiencing a pulmonary embolism, which requires immediate assessment. Choice A is incorrect because although severe pain is present, it is more indicative of musculoskeletal issues related to urolithiasis rather than a life-threatening condition. Choice B, related to acute cholecystitis, is less urgent than choice D as the pain radiating to the right shoulder is a common symptom but does not indicate an immediate life-threatening situation. Choice C, regarding a client post-total knee arthroplasty with a pain level of 8, is important but not as urgent as a potential pulmonary embolism in choice D.

2. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?

Correct answer: B

Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.

3. A client with neuropathic pain has a new prescription for amitriptyline once per day. What should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: 'Increase fluids while on this medication.' Amitriptyline can cause side effects like dry mouth and urinary retention. Increasing fluids can help alleviate these side effects. Choices A, C, and D are incorrect. Taking the medication with meals or only at night is not specifically related to managing the side effects of amitriptyline. Reporting yellowing of the skin is important but not directly related to the side effects of this medication.

4. A healthcare professional is reviewing the lab results of a client with liver disease. Which finding requires immediate intervention?

Correct answer: C

Rationale: Elevated ammonia levels in a client with liver disease can lead to hepatic encephalopathy, requiring immediate intervention. Ammonia is a neurotoxin that can cause cognitive impairment and altered mental status. Elevated bilirubin levels (Choice A) are common in liver disease but do not require immediate intervention. Low albumin levels (Choice B) and low hemoglobin levels (Choice D) are also common in liver disease but do not pose an immediate threat compared to elevated ammonia levels.

5. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.

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