ATI RN 3.0 CLINICAL JUDGMENT PRACTICE 1
A nurse is caring for a client who has COPD.
Nurses' Notes
0800:
The client is lying in bed with the head of bed elevated to 45°. The client appears to be
underweight and has generalized pallor and clubbing on fingers. Lung sounds are
decreased throughout with inspiratory wheezes. Heart rate is regular. Albuterol,
indacaterol, and methylprednisolone given with breakfast.
0830:
The client is sitting up in bed. Shortness of breath is noted, inspiratory and expiratory
wheezing.
Vital Signs
0800:
Temperature 36.7° C (98° F)
Heart rate 76/min
Respiratory rate 30/min
BP 110/74 mm Hg
Pulse oximetry 88% 2 L oxygen via nasal cannula
0830:
Temperature 36.7° C (98° F)
Heart rate 86/min
Respiratory rate 35/min
BP 100/78 mm Hg
Pulse oximetry 90% 2 L oxygen via nasal cannula
Medication Administration RecordAlbuterol aerosolized 5 mg in 3 mL saline every 1 hr
PRN
Indacaterol 75 mcg inhaled once a day @ 0800
Methylpredniso - Answers :Assist the client with controlled coughing.
Instruct the client to use pursed lip breathing.
Obtain an order for an additional dose of albuterol.
A nurse is caring for a client in a prenatal clinic.
Nurses Notes
28 weeks of gestation:
The client reports they can feel the baby kick every hour. The client also reported that
they get headaches weekly.
, 30 weeks of gestation:
The client reports a constant headache for the last 3 days that is unrelieved by
acetaminophen. The client also reports blurred vision, right side upper abdominal pain,
and decreased fetal movement.
History and Physical
28 weeks of gestation:
Fundal height 26 cm
80.5 kg (177 lb) client has gained weight since visit 2 weeks ago
Deep tendon reflexes 2+
Negative clonus
1+ pitting pedal edema
Swelling of the hands
30 weeks of gestation:
Fundal height 26 cm
82.7 kg (182 lb) client has gained weight since visit 2 weeks ago
Epigastric pain
Deep tendon reflexes 3+
Positive clonus
3+ pitting pedal edema
Swelling of the face and hands
Diagnostic Results
30 weeks of gestation:
Nonreactive nonstr - Answers :Liver panel results
Blood pressure
Nonstress test results
Fundal height
Platelet count
Fetal movement
A nurse is caring for a client in a clinic.
Medical History
01/15/XX:
Metabolic syndrome
Nicotine use disorder
Moderate, persistent asthma
Vital Signs
01/15/XX:
BP 130/84 mm Hg
A nurse is caring for a client who has COPD.
Nurses' Notes
0800:
The client is lying in bed with the head of bed elevated to 45°. The client appears to be
underweight and has generalized pallor and clubbing on fingers. Lung sounds are
decreased throughout with inspiratory wheezes. Heart rate is regular. Albuterol,
indacaterol, and methylprednisolone given with breakfast.
0830:
The client is sitting up in bed. Shortness of breath is noted, inspiratory and expiratory
wheezing.
Vital Signs
0800:
Temperature 36.7° C (98° F)
Heart rate 76/min
Respiratory rate 30/min
BP 110/74 mm Hg
Pulse oximetry 88% 2 L oxygen via nasal cannula
0830:
Temperature 36.7° C (98° F)
Heart rate 86/min
Respiratory rate 35/min
BP 100/78 mm Hg
Pulse oximetry 90% 2 L oxygen via nasal cannula
Medication Administration RecordAlbuterol aerosolized 5 mg in 3 mL saline every 1 hr
PRN
Indacaterol 75 mcg inhaled once a day @ 0800
Methylpredniso - Answers :Assist the client with controlled coughing.
Instruct the client to use pursed lip breathing.
Obtain an order for an additional dose of albuterol.
A nurse is caring for a client in a prenatal clinic.
Nurses Notes
28 weeks of gestation:
The client reports they can feel the baby kick every hour. The client also reported that
they get headaches weekly.
, 30 weeks of gestation:
The client reports a constant headache for the last 3 days that is unrelieved by
acetaminophen. The client also reports blurred vision, right side upper abdominal pain,
and decreased fetal movement.
History and Physical
28 weeks of gestation:
Fundal height 26 cm
80.5 kg (177 lb) client has gained weight since visit 2 weeks ago
Deep tendon reflexes 2+
Negative clonus
1+ pitting pedal edema
Swelling of the hands
30 weeks of gestation:
Fundal height 26 cm
82.7 kg (182 lb) client has gained weight since visit 2 weeks ago
Epigastric pain
Deep tendon reflexes 3+
Positive clonus
3+ pitting pedal edema
Swelling of the face and hands
Diagnostic Results
30 weeks of gestation:
Nonreactive nonstr - Answers :Liver panel results
Blood pressure
Nonstress test results
Fundal height
Platelet count
Fetal movement
A nurse is caring for a client in a clinic.
Medical History
01/15/XX:
Metabolic syndrome
Nicotine use disorder
Moderate, persistent asthma
Vital Signs
01/15/XX:
BP 130/84 mm Hg
