a nurse on an acute med surgical unit is performing assessments on a group of clients which is the highest priority
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?

Correct answer: A

Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.

2. A client newly diagnosed with asthma is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Keeping a diary of albuterol use helps monitor the frequency and severity of asthma symptoms, which can guide the healthcare provider in adjusting treatment as needed. Option A is incorrect because fluticasone is a controller medication used for long-term management, not for treating acute asthma attacks. Option B is incorrect as using a peak flow meter once a week may not provide real-time information on asthma control. Option D is incorrect as limiting fluid intake does not directly prevent mucus production in asthma.

3. A healthcare professional is assessing a client who is experiencing a thyroid storm. Which of the following is an expected finding?

Correct answer: C

Rationale: In a thyroid storm, which is a severe complication of hyperthyroidism, hypertension is an expected finding. Other common manifestations include tachycardia, hyperthermia, and agitation. Hypothermia (choice A) is not expected in a thyroid storm as the body temperature is usually elevated due to increased metabolic rate. Bradycardia (choice B) is not typical in a thyroid storm; instead, tachycardia is more common. Lethargy (choice D) is not a typical finding in a thyroid storm, as clients are usually agitated due to excess thyroid hormone levels.

4. A healthcare professional is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?

Correct answer: C

Rationale: An increased hematocrit level indicates dehydration or fluid volume deficit. Hematocrit measures the proportion of blood volume that is occupied by red blood cells, and when a client is experiencing fluid volume deficit, there is less fluid in the blood, causing the concentration of red blood cells to be higher, leading to an increased hematocrit level. Decreased hematocrit (Choice A) is more indicative of fluid volume excess. Increased BUN (Choice B) is associated with renal function and dehydration but is not a direct indicator of FVD. Decreased urine specific gravity (Choice D) is also associated with dehydration, but an increased hematocrit is a more specific indicator of fluid volume deficit.

5. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?

Correct answer: C

Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.

Similar Questions

A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?
A healthcare professional is preparing to administer heparin 8,000 units subcutaneously every eight hrs. The amount available is heparin injection 10,000 units/mL. How many milliliters should the healthcare professional administer per dose?
A nurse is caring for a client who is taking warfarin. The nurse notes that the client has a new prescription for amoxicillin. Which of the following laboratory tests should the nurse monitor closely?
A client had a pituitary tumor removed. Which of the following findings requires further assessment?
A client is receiving oxytocin to augment labor. The contractions are occurring every 45 seconds, and the fetal heart rate is 170-180 beats/min. What action should the nurse take?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses