Swift River- ATI| 66 Questions and
Answers 100% Correct.
Arthur Thomason 56-year-old MVA victim, fourth day post op with a splenectomy and femur
repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L
of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts
from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly
elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last
night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears
ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes.
Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2
(Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in
overall condition. - ANSWER-Alteration in comfort: True
Alteration in gas exchange: True
Ineffectual airway clearance: True
Potential for shock: True
Prolonged confusion: True
Anxiety/fear: True
Potential for failure to thrive: True
Donald Lyles 52-year old male, was admitted yesterday evening for stabilization of his
uncontrolled type II diabetes. He is married, and his wife is requesting to stay at his side. His
HbgA1c is 10.6%. He has a history of a Myocardial Infarction, MI, one year ago, and has
refused all cardiac rehab, and has not had another cardiac event. He refuses to comply with
dietary recommendations. His BMI is 37. Vital signs are: BP: 146/94, P: 88, R: 22, T: 99.2,
PaO2: 94% Blood glucose upon admission is 340 mg/dl - ANSWER-Select appropriate
nursing concerns below based upon patient report above:
Acute discomfort False
Alteration in comfort False
Knowledge Deficit True
Nausea False
,Potential for falls False
Potential for infection True
Estelle Hatcher
Estelle Hatcher 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known
allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and
cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV
maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with
minimal assistance. Family at beside. Dr. Sangerstien - ANSWER-Select appropriate nursing
concerns below based upon patient report above:
Physiological
Acute discomfort False
Alteration in bowel elimination: diarrhea: false
Alteration in comfort: true
Alteration in mobility: true
Decreased activity tolerance: false
Potential for alteration in electrolyte balance: true
Safety
Fear: false
Ineffectual self-health management: false
Knowledge deficit: true
Potential for falls: true
Potential for infection: true
Sleep deficit: false
Charlie Raymond 65-year-old male who was admitted to a negative pressure room on Med-
Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes type II, and
a recent myocardial infarction. He is a retired postal worker who lives at home with his wife.
He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. Initially this cardiologist
was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide
(Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89
Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula.
The patient/family is fearing the worst due to COVID-19 Pandemic. - ANSWER-Acute
discomfort False
, Alteration in body image False
Alteration in gas exchange True
Alteration in physical mobility True
Alteration in skin integrity False
.Bleeding False
Death anxiety True
Esteem False
.Ineffectual breathing pattern True
Knowledge deficit True
Sudden confusion False
Electrolyte Imbalance: F
Potential for alteration in mobility: T
Potential for alteration in skin integrity: F
Safety
Potential for falls: T
Sleep deficit: T
Sarah Getts 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9,
Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP
102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular
Answers 100% Correct.
Arthur Thomason 56-year-old MVA victim, fourth day post op with a splenectomy and femur
repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L
of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts
from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly
elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last
night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears
ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes.
Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2
(Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in
overall condition. - ANSWER-Alteration in comfort: True
Alteration in gas exchange: True
Ineffectual airway clearance: True
Potential for shock: True
Prolonged confusion: True
Anxiety/fear: True
Potential for failure to thrive: True
Donald Lyles 52-year old male, was admitted yesterday evening for stabilization of his
uncontrolled type II diabetes. He is married, and his wife is requesting to stay at his side. His
HbgA1c is 10.6%. He has a history of a Myocardial Infarction, MI, one year ago, and has
refused all cardiac rehab, and has not had another cardiac event. He refuses to comply with
dietary recommendations. His BMI is 37. Vital signs are: BP: 146/94, P: 88, R: 22, T: 99.2,
PaO2: 94% Blood glucose upon admission is 340 mg/dl - ANSWER-Select appropriate
nursing concerns below based upon patient report above:
Acute discomfort False
Alteration in comfort False
Knowledge Deficit True
Nausea False
,Potential for falls False
Potential for infection True
Estelle Hatcher
Estelle Hatcher 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known
allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and
cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV
maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with
minimal assistance. Family at beside. Dr. Sangerstien - ANSWER-Select appropriate nursing
concerns below based upon patient report above:
Physiological
Acute discomfort False
Alteration in bowel elimination: diarrhea: false
Alteration in comfort: true
Alteration in mobility: true
Decreased activity tolerance: false
Potential for alteration in electrolyte balance: true
Safety
Fear: false
Ineffectual self-health management: false
Knowledge deficit: true
Potential for falls: true
Potential for infection: true
Sleep deficit: false
Charlie Raymond 65-year-old male who was admitted to a negative pressure room on Med-
Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes type II, and
a recent myocardial infarction. He is a retired postal worker who lives at home with his wife.
He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. Initially this cardiologist
was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide
(Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89
Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula.
The patient/family is fearing the worst due to COVID-19 Pandemic. - ANSWER-Acute
discomfort False
, Alteration in body image False
Alteration in gas exchange True
Alteration in physical mobility True
Alteration in skin integrity False
.Bleeding False
Death anxiety True
Esteem False
.Ineffectual breathing pattern True
Knowledge deficit True
Sudden confusion False
Electrolyte Imbalance: F
Potential for alteration in mobility: T
Potential for alteration in skin integrity: F
Safety
Potential for falls: T
Sleep deficit: T
Sarah Getts 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9,
Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP
102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular
