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
Assessm...
ATI Comp Practice A w/ NGN Exam 2023 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. - 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 fou r 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 D - 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 - The client is at risk for developing seizures as evidenced by blood pressure. A nurse is caring for a client who has schizophrenia in an inpatient facility. Medication Administration Record 0730:Clozapine 100 mg PO daily Aripiprazole 5 mg PO daily Multivitamin PO daily Laboratory Results 0730:Sodium 125 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 90 mEq/L (98 to 106 mEq/L) BUN 8 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Vital Signs 1230: Temperature 37.6° C (99.7° F)Heart rate 98/min Respiratory rate 20/min Blood pressure 142/92 mm Hg Oxygen saturation 100% on room air 1500: Temperature 37.1° C (98.8° F) Heart rate 104/min Respiratory rate 24/min Blood pressure 150/90 mm Hg Oxygen saturation 100% on room air Nurses' Notes 0730:Client sleeping. Lungs clear to auscultation bilaterally. Hyperactive bowel sounds noted x 4. Abdomen soft and nontender. Small bruise noted on right hand. Family at bedside. Family states client is diagnosed w - ENTER ANSWER A nurse is caring for a client who is in the spinal cord injury (SCI) unit. Nurses' Notes Day 1, 1700: Client admitted to SCI 3 days ago following C7 injury.Urinary output 800 mL in indwelling urinary catheter over last 12 hr.Day 2, 0600: Client has nonproductive cough. Urinary output 100 mL in indwelling urinary catheter over last 6 hr. Vital Signs Day 1, 2200: Temperature 37.2° C (99.0° F) Heart rate 74/min Respiratory rate 20/min Blood pressure 110/60 mm Hg Oxygen saturation 95% on room air Day 2, 0600: Temperature 37.8° C (100° F) Heart rate 54/min Respiratory rate 26/min Blood pressure 96/60 mm Hg Oxygen saturation 90% on room air Physical Examination Day 1, 1700: Lung sounds diminished in lower lobes. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Skin is cool, pale, and dry to touch. Day 2, 0600: Adventitious lung sounds auscultated in lower lobes bilaterally. - The nurse should first address the client's oxygen saturation followed by the client's urinary output. A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? - Fiber attention deficit hyperactivity disorder (ADHD) - ENTER ANSWER intellectual disability (ID) - ENTER ANSWER
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