ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Nurses' Notes
Day 1:
1000:
Client is alert to person, place, and time. Client is short of breath and leans forward to breathe easier. Lung sounds are diminished in bilateral bases with occasional wheezes. Nonproductive cough. Heart rate is regular. +2 pulses in all extremities.
1500:
Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Heart rate is regular. +2 pulses in all extremities. Client is oriented to person, place and time. Client is restless. Pupils are reactive to light. Client is diaphoretic with cyanotic mucous membranes
Vital Signs
1000:
Temperature: 37.1°C (98.8°F)
Heart Rate: 100/min
Respiratory Rate: 22/min (irregular)
Blood Pressure: 164/80 mm Hg
Oxygen Saturation: 92% on room air
1500:
Temperature: 37.3°C (100.3°F)
Heart Rate: 110/min
Respiratory Rate: 26/min (irregular)
Blood Pressure: 110/58 mm Hg
Oxygen Saturation: 87% on room air
Question 1 of 5
A nurse is caring for a client who has COPD. Select the findings below that require immediate follow-up.
Correct Answer: B,C,E,F
Rationale: Restlessness, tachypnea, yellow mucous, and wheezes/crackles indicate worsening COPD requiring intervention.
Extract:
Question 2 of 5
Correct Answer:
Rationale:
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
Correct Answer:
Rationale:
Question 5 of 5
Correct Answer:
Rationale: