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ATI RN Fundamentals Online Practice 2023 B
Total Questions : 59
Showing 10 questions, Sign in for more- Client 1: The client is admitted with a new diagnosis of rheumatoid arthritis.
- Client 2: The client has a history of hyperlipidemia. Atorvastatin 20 mg PO was administered as prescribed.
- Client 3: The client is 1 day postoperative. The client reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous was administered as prescribed.
- Client 4: The client is admitted with a new diagnosis of heart failure.
- Client 5: The client has a stage 2 pressure injury on the left heel.
- Client 6: The client is admitted with a new diagnosis of diabetes mellitus.
A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.
Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:
Week 1:
- Hematocrit (Hct): 42% (Normal range: 37% to 47%)
- Hemoglobin (Hgb): 15 g/dL (Normal range: 12 to 16 g/dL)
- White Blood Cell (WBC) count: 8,000/mm² (Normal range: 5,000 to 10,000/mm²)
- Platelet count: 350,000/mm² (Normal range: 150,000 to 400,000/mm²)
- Potassium: 3.7 mEq/L (Normal range: 3.5 to 5 mEq/L)
Week 2:
- Hematocrit (Hct): 37% (Normal range: 37% to 47%)
- Hemoglobin (Hgb): 12 g/dL (Normal range: 12 to 16 g/dL)
- White Blood Cell (WBC) count: 6,000/mm² (Normal range: 5,000 to 10,000/mm²)
- Platelet count: 100,000/mm² (Normal range: 150,000 to 400,000/mm²)
- Potassium: 3.6 mEq/L (Normal range: 3.5 to 5 mEq/L)
A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks:
Complete the following sentence by using the lists of options. The client is at risk for
Explanation
The client is at risk for Bleeding as evidenced by the Decrease in Platelet count from 350,000/mm² to 100,000/mm².
Rationale for Bleeding: Platelets are a crucial component of the blood that helps in clotting and preventing excessive bleeding. A decrease in platelet count from 350,000/mm² to 100,000/mm² is significant and puts the client at risk for bleeding. This is because when platelet levels fall below the normal range (150,000 to 400,000/mm²), the body’s ability to form clots and stop bleeding is compromised.
Rationale for Anemia: The client’s Hemoglobin level has decreased from 15 g/dL to 12 g/dL, which is at the lower end of the normal range (12 to 16 g/dL). However, it is still within the normal range, so the client is not currently at risk for anemia.
Rationale for Infections: The client’s White Blood Cell (WBC) count has decreased from 8,000/mm² to 6,000/mm², but it is still within the normal range (5,000 to 10,000/mm²). Therefore, the client is not currently at risk for infections.
Rationale for Cardiac arrhythmias: The client’s Potassium level has slightly decreased from 3.7 mEq/L to 3.6 mEq/L, but it is still within the normal range (3.5 to 5 mEq/L). Therefore, the client is not currently at risk for cardiac arrhythmias.
- 0700 hrs:
- Blood Pressure (BP): 138/72 mm Hg
- Heart rate: 80/min
- Respirations: 22/min
- Temperature: 38.3°C (101.1°F)
- Oxygen saturation: 90% on room air
- 1100 hrs:
- Blood Pressure (BP): 132/68 mm Hg
- Heart rate: 92/min
- Respirations: 24/min
- Temperature: 39.0°C (102.2°F)
- Oxygen saturation: 88% on room air
- 1500 hrs:
- Blood Pressure (BP): 126/64 mm Hg
- Heart rate: 100/min
- Respirations: 26/min
- Temperature: 39.5°C (103.1°F)
- Oxygen saturation: 86% on room air
- 0700 hrs:
- The client is alert but appears fatigued. Complaints of increased shortness of breath over the past 24 hours. The client has a productive cough with thick, yellow sputum. The client reports feeling increasingly weak and dizzy. Mild confusion is noted, with difficulty maintaining focus during the assessment. The client is diaphoretic and has been experiencing chills intermittently. The skin appears flushed and warm to the touch.
- 1100 hrs:
- The client is visibly distressed and reports worsening dyspnea. The cough is now accompanied by greenish, foul- smelling sputum. The client exhibits increased confusion and disorientation. The skin is cool and clammy, with noticeable pallor. Respiratory effort is labored, with audible wheezing and crackles upon auscultation. The client reports persistent nausea and decreased appetite. There is a noticeable increase in fatigue and lethargy.
- 1500 hrs:
- The client is significantly drowsy and difficult to arouse. Respiratory distress is evident, with use of accessory muscles for breathing. The sputum is now blood-tinged and the cough is frequent and severe. The skin is very pale, with a bluish tinge noted around the lips. The client shows signs of hypotension and rapid pulse. There is an overall decline in mental status, with severe confusion and disorientation. The client complains of severe weakness and generalized body aches.
- Diabetes mellitus, well-managed with medication
- Chronic obstructive pulmonary disease (COPD)
- History of hypertension
- No known drug allergies
- Recent travel to an area with known respiratory infections
- 0700 hrs:
- Chest X-ray: Mild infiltrates in the lower lobes
- CBC: Elevated white blood cell count (WBC) 12,000/µL
- 1100 hrs:
- Chest X-ray: Progression of infiltrates with more pronounced consolidation
- CBC: Further elevated white blood cell count (WBC) 15,000/µL; Elevated C-reactive protein (CRP)
- 1500 hrs:
- Chest X-ray: Extensive consolidation with possible pleural effusion
- CBC: High white blood cell count (WBC) 18,000/µL; Elevated CRP; Low hemoglobin (Hb)
- 0700 hrs:
- Antibiotic therapy initiated: Levofloxacin 500 mg IV every 24 hours
- Oxygen therapy: 2 L/min via nasal cannula
- 1100 hrs:
- Increased oxygen therapy to 4 L/min via nasal cannula
- Addition of nebulized bronchodilators
- 1500 hrs:
- Oxygen therapy increased to 6 L/min via non-rebreather mask
- Initiation of intravenous corticosteroids
A 60-year-old male client is admitted to the medical-surgical unit. The client is experiencing a worsening of symptoms over the last 24 hours. The client's initial presentation was similar to previous days, but his condition has deteriorated.
Based on the evolution of the client’s condition and the provided exhibits, select all that apply. Which of the following actions should the nurse include in the client's care plan?
- The client reports a sudden onset of chest tightness and difficulty breathing starting approximately 30 minutes ago.
- The client is anxious and visibly distressed, clutching her chest intermittently.
- She has a history of hypertension and diabetes, which are being managed with medication.
- On examination, the client is sitting upright and appears to be in moderate respiratory distress.
- The client mentions feeling lightheaded and reports a slight headache.
- She is sweating profusely and her skin is pale.
- The client denies any recent physical exertion or known exposure to irritants.
- Temperature: 37.2°C (99.0°F)
- Heart Rate: 104 beats per minute
- Respiratory Rate: 22 breaths per minute
- Blood Pressure: 158/92 mmHg
- The client’s lungs exhibit bilateral wheezing and crackles upon auscultation.
- There is no visible swelling or edema in the extremities.
- The client has a dry cough that is intermittent.
- No cyanosis is noted around the lips or extremities.
- The client’s skin is cool and clammy.
- The client appears slightly disoriented when asked questions.
- There is no sign of trauma or injury.
Scenario:
A 45-year-old female client is admitted to the emergency department with complaints of sudden shortness of breath and chest tightness. She has a history of hypertension and diabetes.
A nurse is assessing the client at 0700 hrs. Which of the following actions should the nurse take first? A Initiate a cardiac enzyme panel
A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient’s vital signs at 0800 and 0815 are given.
Heart rate of 110 bpm
Complete the following sentence using the list of options.
The patient exhibits symptoms of ________
Which of the following actions should the nurse take to ensure the medication reaches the inner ear?
The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?
Which of the following actions should the nurse take?
What does that involve?” Which of the following responses should the nurse make?
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