a nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first

ATI LPN

PN ATI Comprehensive Predictor

1. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?

A. A client who is 1 hr postoperative and has hypoactive bowel sounds.
B. A client who has a fractured left tibia and pallor in the affected extremity.
C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses.
D. A client who has an elevated AST level following the administration of azithromycin.

Correct answer: B

Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.

2. What are the risk factors for developing pneumonia in older adults?

A. Immobility and decreased lung function
B. Poor hygiene and aspiration
C. Use of respiratory equipment and medications
D. Poor nutritional status and compromised immune system

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

3. How should a healthcare professional manage a patient with diarrhea?

A. Provide oral fluids and monitor stool consistency
B. Administer antidiarrheal medications and monitor hydration
C. Monitor for electrolyte imbalances and provide antibiotics
D. Provide a low-fiber diet and monitor weight

Correct answer: A

Rationale: For a patient with diarrhea, the priority is to manage dehydration by providing oral fluids and monitoring stool consistency. Option B suggesting administering antidiarrheal medications is not recommended as it may prolong the infection by preventing the body from expelling the infectious agent. Option C is incorrect because antibiotics are not routinely indicated for diarrhea unless there is a specific bacterial infection. Option D is not the most appropriate initial intervention for managing diarrhea since a low-fiber diet may not provide adequate nutrition for the patient or help resolve the underlying cause of diarrhea.

4. A nurse is preparing a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?

A. Hgb 12.8 g/dl.
B. Potassium 4.2 mEq/L.
C. RBC 4.4 million/mm3.
D. Platelets 100,000/mm3.

Correct answer: D

Rationale: The correct answer is D: "Platelets 100,000/mm3." A platelet count of 100,000/mm3 is low and increases the client's risk for bleeding, which is crucial information to communicate during the change-of-shift report. Choices A, B, and C provide values within normal ranges and are not directly related to the client's postoperative status or risk for complications. Therefore, they are not the priority information to include in the report.

5. A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

A. Remove the weights
B. Ensure the weights hang freely
C. Increase the traction force
D. Loosen the ropes

Correct answer: B

Rationale: The correct action the nurse should take when caring for a client in Buck's traction is to ensure the weights hang freely. This is essential to maintain proper alignment and ensure the effectiveness of Buck's traction. Removing the weights (Choice A) would be incorrect and could compromise the treatment. Increasing the traction force (Choice C) can lead to excessive pressure and potential harm to the client. Loosening the ropes (Choice D) would also be inappropriate as it can disrupt the traction's effectiveness and alignment.