ATI Ns 117 Fundamentals Exam

Extract:

Vital Signs
Day 1
• Temperature 38 °C (100.4oF)
• BP 118/72 mm Hg
• Heart rate 90/min
• Respiratory rate 18/min
• Oxygen saturation 95% on room air
Day 2:
• Temperature 38.5°C (101.3 oF)
• BP 108/74 mm Hg
• Heart rate 92/min
• Respiratory rate 18/min
• Oxygen saturation 88% on room air
Nurses’ Notes
• Mucous membranes pink, skin warm and dry.
• Coughing and clearing throat when eating.
• Voice hoarse after swallowing.
• Bilateral breath sounds with wheezing heard in upper lobes.

Question 1 of 5

A nurse is assisting with the care of a client who had a stroke.Select all the findings that require immediate follow-up. .

A. Coughing and clearing throat when eating. B. Voice hoarse after swallowing. C. Temperature 38 °C (100.4 °F) D. Bilateral breath sounds with wheezing heard in upper lobes. E. Oxygen saturation 88% on room air F. Mucous membranes pink, skin warm and dry.

Correct Answer: A,B,C,D,E

Rationale: The correct answer is A, B, C, D, and E. Each of these findings requires immediate follow-up due to potential complications in a stroke patient. A: indicates a risk of aspiration, leading to choking. B: suggests possible dysphagia, which can result in aspiration pneumonia. C: signifies a fever, which can indicate infection or other complications. D: wheezing may indicate respiratory distress or pneumonia. E: low oxygen saturation may lead to hypoxia and requires immediate intervention to prevent further complications. Other choices are incorrect as they do not pose immediate risks to the patient's health in the context of a stroke.

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Question 2 of 5

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Question 5 of 5

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ATI Ns 117 Fundamentals Exam | Nurselytic

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