ATI Comp Practice A WITH NGN 150 Q/A 2023/2024

ATI Comp Practice A WITH NGN 150 Q/A 2023/2024 A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Vital Signs • Temperature 37.7° C (99.8° F)• Heart rate 82/min• Respiratory rate 16/min• Blood pressure 127/80 mm Hg��� Oxygen saturation 99% on room air Assessment Height 157.5 cm (62 in)Weight 90 kg (198 lb)Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities. Distended veins noted on right lower extremity. Nurses' Notes Client reports pain at abdominal incision site as 4 on a 0 to 10 scale.Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching.Reports that right lower extremity pain has been intermittent for about the last 2 months.Denies current left lower extremity pain. - ~ ANSWER Potential condition: varicose veins Actions to take: apply compression stockings and elevate extremity Parameters to monitor: Edema and pruritis of right lower extremity A nurse is caring for a preschooler on the pediatric unit. Provider Prescriptions Day 1, 2350:Admit for observation.Obtain vital signs every 4 hr and PRN.Administer oxygen 2 L/min via nasal cannula to maintain oxygen saturation above 95%.Initiate saline lock.Administer ceftriaxone 250 mg IV every 12 hr.Administer acetaminophen oral suspension 240 mg every 4 hr PRN for temperature greater than 38° C (100.4° F).Place on regular diet and encourage oral fluids of preschooler's choice.Monitor intake and output every 8 hr. Assessment Day 2, 0030:Preschooler lying on bed, awake and alert. Breath sounds with wheezing auscultated on expiration on the right side. Nonproductive cough with no retractions or nasal flaring observed. Abdomen soft and nondistended, bowel sounds active in all four quadrants. Preschooler reports headache and pain in abdomen. Rates pain in abdomen as a 2 on a 0 to 10 FACES pain scale. Vital Signs Day 2, 0030:Temperature 38.1° C (100.6° F)Heart rate 122/minRespiratory rate 25/minOxygen saturation 98% on oxygen at 2 L/min via nasal cannulaWeight 17.3 kg (38 lb)Height 102.3 cm (40.3 in) Nurses' Notes Day 2, 0100:Saline lock inserted on first attempt. Assisted preschooler to right side-lying position for splinting. Administered ceftriaxone IV. Caregiver at bedside.Day 2, 0130:Preschooler sitting up in bed, appearing anxious and flushed. Lips swollen. Preschooler scratching hives that have appeared on both upper extremities. History and Physical 2250:Admitted from the emergency department with a diagnosis of pneumonia on the right side with mild pleural effusion Medical history: Preschooler has a history of asthma Allergies: No known allergies - ~ ANSWER Administer epinephrine IM. Administer 0.9% sodium chloride IV. Monitor vital signs frequently. Discontinue the IV medication. A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. History and Physical Client is G2P2 at 38 weeks of gestation Diagnosed with preeclampsia at 32 weeks of gestation Scheduled repeat cesarean birth Diagnosed with gestational diabetes mellitus at 29 weeks of gestation Nurses' Notes 1500: Dressing dry and intact. Fundus firm midline at umbilicus. Scant lochia rubra. Client rates incisional pain as a 3 on a scale of 0 to 10, denies need for analgesia. Indwelling urinary catheter removed.1700: Client reports headache with pain rated at 4 on a scale of 0 to 10. Analgesic administered.1800: Client reports blurred vision and nausea. Rates pain from headache as a 6 on a scale of 0 to 10. Deep tendon reflexes 4+, clonus positive. Vital Signs 1500: Temperature 36.6° C (97.9° F)Heart rate 86/minRespiratory rate 18/minBlood pressure 155/90 mm HgOxygen saturation 98% on room air1800: Heart rate 96/minRespiratory rate 22/minBlood pressure 185/115 mm HgOxygen saturation 96% on room air Laboratory Results 1700: Capillary blood glucose (casual) 120 mg/dL (less than 200 mg/dL) WBC 22,000/mm3 (5,000 to 10,000/mm3) Hct 37% (greater than 33%) Hgb 12 g/dL (greater than 11 g/dL) Platelets 160,000/mm3 (150,000 to 400,000/mm3) - ~ ANSWER The client is at risk for developing seizures as evidenced by blood pressure.