ATI Advanced Med Surg Final Exam 0924 | Nurselytic

Extract:

Physical Examination
0800:
Alert and oriented to person and place
Skin pale and dry
Pupils equal, round, and reactive to light and accommodation Mucous
membranes moist and pink
Heart sounds regular and moderate
Peripheral pulses moderate
Capillary refill 3 seconds
Lungs sounds clear to auscultation bilaterally
Respirations labored at rest
Abdomen soft and nontender, active bowel sounds x 4 quadrants
No peripheral edema
Reports slight midsternal chest pain, rates pain as a 2 on a 0 to 10 pain scale
States they have been weak for the past 4 months with dizziness. Denies dizziness at this time.
1300
Returns to room after insertion of permanent pacemaker Alert and oriented to person, needs cues for time and place
Skin cool and dry
Heart sounds regular, heart rate 72/min
Lung sounds are coarse bilaterally
Hyperresonance noted upon percussion of chest wall
Respiratory rate 24/min and slightly labored
Oxygen saturation 2 U/min per nasal cannula 98%
Reports slight incisional pain left upper chest area
Small amount red drainage present on dressing over incisional site

Diagnostic Results
RBC count 5.2 million/mm3 (4.7 to 6.1 million/mm3) WBC count 7,000 mm (5,000 to 10,000 mm3)
Hemoglobin 15.4 g/dL (14 to 18 g/dL)
Hematocrit 48% (42% to 52%)
Platelets 250,000/mm3 (150,000 to 400,000/mm3)
Basic Metabolic Profile:
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)
Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)
Carbon Dioxide 27 mEq/L (23 to 30 mEq/L) Chloride 101 mEq/L (98 to 106 mEq/L) Glucose 80 mg/dL (74 to 106 mg/dL) Potassium 5.1 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L)

Vital Signs
Temperature 36 Cm
Apical pulse 42min
Respiratory rate 25/min
Blood pressure 106/58 mm Hg
Oxygen saturation 54% on room air

Extract: