after change of shift report which patient should the nurse assess first

ATI RN

ATI Leadership Proctored Exam 2019

1. After receiving change-of-shift report, which patient should the nurse assess first?

A. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12%
B. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL
C. 40-year-old who is pregnant and has an oral glucose tolerance test result of 202 mg/dL
D. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

Correct answer: B

Rationale: The correct answer is B because the patient with a blood glucose level of 40 mg/dL (hypoglycemia) needs immediate attention. Hypoglycemia is an emergency situation that requires prompt intervention to prevent adverse effects such as seizures or loss of consciousness. Assessing and managing this patient first is crucial to prevent further deterioration. Choices A, C, and D do not present immediate life-threatening situations requiring urgent intervention like severe hypoglycemia does. While a high hemoglobin A1C level (choice A), an abnormal oral glucose tolerance test result (choice C), and acute abdominal pain (choice D) are important issues, they do not pose an immediate threat to the patient's life compared to severe hypoglycemia.

2. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

A. Make sure the enteral formula is at room temperature.
B. Wipe the top of the formula can with alcohol.
C. Rinse the feeding bag with water between feedings.
D. Tell the client to keep the head of the bed elevated at least 30�

Correct answer: B

Rationale:

3. An RN enters a patient�s room to place an indwelling urinary catheter, as ordered by the health-care professional. The client is alert and oriented and tells the RN he wants to leave the hospital now and not receive further treatment. Which of the following actions by the RN would be considered false imprisonment?

A. The RN tells the client he is not allowed to leave until the physician has released him.
B. The RN asks the client why he wishes to leave.
C. The RN asks the client to explain what he understands about his medical diagnosis.
D. The RN asks the client to sign an against medical advice discharge form.

Correct answer: A

Rationale: Verbal or physical detainment of a client who desires to leave the institution is false imprisonment.

4. Nonverbal messages in communication, including body language and environmental factors, are called ___________.

A. lateral communication
B. upward communication
C. metacommunications
D. downward communication

Correct answer: C

Rationale: Nonverbal messages in communication, such as body language and environmental factors, are termed metacommunications. Choice A, lateral communication, refers to communication between individuals or groups on the same hierarchical level. Choice B, upward communication, involves the flow of information from lower levels to higher levels in an organization. Choice D, downward communication, relates to the transmission of information from higher levels to lower levels within an organization. Therefore, the correct term for nonverbal messages in communication is metacommunications.

5. What is the main purpose of a nursing code of ethics?

A. To protect the rights and dignity of patients
B. To ensure compliance with healthcare laws
C. To set standards for clinical practice
D. To provide a framework for ethical decision-making in nursing practice

Correct answer: D

Rationale: The main purpose of a nursing code of ethics is to provide a framework for ethical decision-making in nursing practice. While choice A is important, the primary focus of a nursing code of ethics is not solely to protect the rights and dignity of patients but to guide nurses in making ethical decisions. Choice B is more related to legal requirements, not the ethical aspects covered by a code of ethics. Choice C, setting standards for clinical practice, is important but distinct from the primary purpose of a code of ethics, which is centered on ethical decision-making.