a nurse receives a report on four clients which client should the nurse assess first
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form B

1. A nurse receives a report on four clients. Which client should the nurse assess first?

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

2. A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?

Correct answer: C

Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote as it helps reverse the effects. Positioning the client supine (Choice A) may not directly address magnesium sulfate toxicity. Administering dextrose 5% (Choice B) is not the correct intervention for magnesium sulfate toxicity. Methylergonovine IM (Choice D) is used to manage postpartum hemorrhage, not magnesium sulfate toxicity.

3. A nurse is teaching a group of assistive personnel (AP) about caring for clients with Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease can be prone to wandering and getting lost. Providing supervision can help prevent injuries and ensure their safety. Choices A, B, and C are incorrect because explaining procedures clearly, encouraging varied activities, and using simple communication are important but not specifically focused on the safety aspect of preventing clients from getting lost or injured.

4. A client has a new prescription for levothyroxine. What should the nurse teach the client?

Correct answer: D

Rationale: The correct answer is to take levothyroxine on an empty stomach. This is because levothyroxine should be taken in the morning on an empty stomach to ensure proper absorption. Option A is incorrect because levothyroxine is usually advised to be taken in the morning. Option B is not the priority teaching point as monitoring for hypothyroidism symptoms is ongoing care. Option C is incorrect as levothyroxine should not be taken with calcium supplements as they can interfere with its absorption.

5. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: Urge suppression can lead to constipation by delaying bowel movements and causing fecal impaction, especially in postoperative patients. Regular fluid intake (choice A) is important to prevent constipation by maintaining hydration and aiding in bowel movements. Increased physical activity (choice C) helps stimulate bowel function and prevent constipation. Adequate dietary fiber (choice D) is essential for promoting healthy bowel movements and preventing constipation. However, urge suppression (choice B) is the behavior that directly contributes to constipation in this scenario.

Similar Questions

A nurse is planning a staff education program to review nursing interventions for patients who have kidney failure. What source should the nurse identify as the best source for obtaining evidence-based practice information?
When teaching a client about the use of risperidone, which of the following should be included?
When admitting a client with fever, confusion, and decreased level of consciousness, what should the nurse do first after obtaining the client's history and assessment?
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

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