Swift River- ATI Correct 100%
Arthur Thomason 56-year-old MVA victim, fourth day post op with a splenectomy and
femur repair. He is experiencing new onset of shortness of breath and has a nasal
cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily
orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP
now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart
rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His
coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2
(hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is
obviously worsened from the shift before in overall condition. - ANSWER Alteration in
comfort: True
Alteration in gas exchange: True
Ineffectual airway clearance: True
Potential for shock: True
Prolonged confusion: True
Anxiety/fear: True
Potential for failure to thrive: True
Charlie Raymond 65-year-old male who was admitted to a negative pressure room on
Med-Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes
type II, and a recent myocardial infarction. He is a retired postal worker who lives at
home with his wife. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin.
Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond
is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs:
BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2
94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19
Pandemic. - ANSWER Acute discomfort False
Alteration in body image False
Alteration in gas exchange True
Alteration in physical mobility True
Alteration in skin integrity False
.Bleeding False
Death anxiety True
Esteem False
.Ineffectual breathing pattern True
,Knowledge deficit True
Sudden confusion False
Donald Lyles 52-year old male, was admitted yesterday evening for stabilization of his
uncontrolled type II diabetes. He is married, and his wife is requesting to stay at his
side. His HbgA1c is 10.6%. He has a history of a Myocardial Infarction, MI, one year
ago, and has refused all cardiac rehab, and has not had another cardiac event. He
refuses to comply with dietary recommendations. His BMI is 37. Vital signs are: BP:
146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl -
ANSWER Select appropriate nursing concerns below based upon patient report above:
Acute discomfort False
Alteration in comfort False
Knowledge Deficit True
Nausea False
Potential for falls False
Potential for infection True
Estelle Hatcher
Estelle Hatcher 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known
allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert
and cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous
suction. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm.
Ambulates with minimal assistance. Family at beside. Dr. Sangerstien - ANSWER
Select appropriate nursing concerns below based upon patient report above:
Physiological
Acute discomfort False
Alteration in bowel elimination: diarrhea: false
Alteration in comfort: true
Alteration in mobility: true
Decreased activity tolerance: false
Potential for alteration in electrolyte balance: true
Safety
Fear: false
Ineffectual self-health management: false
Knowledge deficit: true
, Potential for falls: true
Potential for infection: true
Sleep deficit: false
Tom Richardson 46yr-old. Dx- urinary stones with 3 episodes/5yrs. Allergic to sulfa
drugs. Vital signs -Temp 98.4,BP 175/105, P 112, RR 28, SaO2 94%; Neuro- WNL's.
Skin warm and pale. Generalized weakness, blood tinged urine and severe pain upon
urination, GI- n/v. Clear liquid diet. Strict I&O and strain all urine, filters in bathroom.
Patient demonstrates urine strain procedure. Severe pain (10/10) medicated q 30
minutes x4 with IV Morphine 2mg with little relief. IV D5 1/2 NS @100ml/hr. Dr. Small at
bedside with patient and family. Stat lithotripsy treatment ordered. Awaiting transport. -
ANSWER Select appropriate nursing concerns below based upon patient report above:
Physiological
Acute discomfort: T
Alteration in nutrition: F
Alteration in urinary elimination: T
Electrolyte Imbalance: F
Potential for alteration in mobility: T
Potential for alteration in skin integrity: F
Safety
Potential for falls: T
Sleep deficit: T
Sarah Getts 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9,
Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP
102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus
irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes
clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with
recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient
very concerned. Dr. Brown - ANSWER Select appropriate nursing concerns below
based upon patient report above:
Physiological
Acute discomfort F
Decrease in fluid volume F
Electrolyte Imbalance T
Ineffectual renal perfusion, risk for T
Potential for alteration in skin integrity: F
Potential for imbalanced fluid volume: T
Safety
