a nurse on the medical surgical unit is receiving reports on four clients which of the following clients should the nurse assess first
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse on the medical-surgical unit is receiving reports on four clients. Which of the following clients should the nurse assess first?

Correct answer: D

Rationale: The client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat should be assessed first. This client may be experiencing airway obstruction due to hematoma or swelling, making it a priority. Options A, B, and C have concerning findings as well, but airway compromise takes precedence over other issues.

2. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?

Correct answer: C

Rationale: The correct information that the nurse should include in the teaching about a CPAP device is that it delivers a preset amount of airway pressure throughout the breathing cycle. This consistent positive airway pressure helps keep the airway open during both inspiration and expiration. Choice A is incorrect as CPAP does not deliver pressure only at the beginning of each breath. Choice B is incorrect because CPAP provides a constant level of pressure without continuous adjustments throughout the cycle. Choice D is incorrect as CPAP does not provide positive pressure at the end of each breath; instead, it maintains a continuous positive pressure.

3. A nurse in the emergency department is prioritizing care for four clients. Which of the following clients should the nurse see first?

Correct answer: D

Rationale: The client with slurred speech, disorientation, and a headache may be experiencing a stroke, a life-threatening condition that requires immediate attention. Identifying and managing a stroke promptly can reduce the risk of long-term disability or complications. The other options, although important, do not present immediate life-threatening conditions that require urgent intervention. A dislocated shoulder, severe joint pain in sickle cell disease, confusion with fever and foul-smelling urine, while concerning, can be addressed after attending to the client with potential stroke symptoms.

4. A nurse is assessing a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

Correct answer: D

Rationale: The correct answer is D: Weight. Desmopressin can cause fluid retention, so monitoring the client's weight is crucial to detect signs of water intoxication or overhydration, which can occur with the medication. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin use in diabetes insipidus. Carbohydrate intake (choice B) is important for diabetes management but is not specifically relevant to monitoring desmopressin therapy. Hematocrit (choice C) is not typically influenced by desmopressin use in diabetes insipidus.

5. A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following factors is strongly associated with this postpartum complication?

Correct answer: A

Rationale: The correct answer is A: Cesarean birth. Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors for DVT include smoking, obesity, and a history of thromboembolism. Vaginal birth, anemia, and multiparity are not strongly associated with an increased risk of deep-vein thrombosis postpartum. It is important to educate clients undergoing cesarean birth about the increased risk of DVT and measures to prevent it, such as early ambulation and the use of compression stockings.

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