Swift River- ATI
Study online at https://quizlet.com/_cdg679
1. Arthur Thomason 56-year-old MVA Alteration in comfort: True
victim, fourth day post op with a Alteration in gas exchange: True
splenectomy and femur repair. He Ineffectual airway clearance: True
is experiencing new onset of short- Potential for shock: True
ness of breath and has a nasal can- Prolonged confusion: True
nula with 2L of Oxygen in place. Anxiety/fear: True
He is restless with slight confu- Potential for failure to thrive: True
sion but is easily orientated with
attempts from nurse. Temperature
spiked during the night to 102.4,
BP now 146/94 which is slightly el-
evated, respirations at 30 bpm and
slightly labored, heart rate 102 ver-
sus 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 inter-
stitial infiltrates in all lobes. Recent
blood gases demonstrate falling
PaO2 (hypoxemia) and increasing
CO2 (Hypercapnia). Mr. Thomason
is anxious and is obviously wors-
ened from the shift before in over-
all condition.
2. Charlie Raymond 65-year-old male Acute discomfort False
who was admitted to a negative
pressure room on Med-Surg for Alteration in body image False
COVID precautions.. He has a histo-
Alteration in gas exchange True
ry of COPD, hypertension, diabetes
type II, and a recent myocardial in-
, Swift River- ATI
Study online at https://quizlet.com/_cdg679
farction. He is a retired postal work- Alteration in physical mobility True
er who lives at home with his wife.
He is on Claforan (cefotaxime) 2 g Alteration in skin integrity False
IV q4hr and sliding scale insulin.
.Bleeding False
Initially this cardiologist was con-
cerned about congestive heart fail-
Death anxiety True
ure and Mr. Raymond is receiving
Furosemide (Lasix) 20 mg IV twice Esteem False
a day for pulmonary edema. Vital
Signs: BP is 145/78, Pulse 89 Res- .Ineffectual breathing pattern True
pirations 24 and slightly labored,
Temperature 100.2 SaO2 94% on 2L Knowledge deficit True
nasal cannula. The patient/family is
fearing the worst due to COVID-19 Sudden confusion False
Pandemic.
3. Donald Lyles 52-year old male, was Select appropriate nursing concerns below based upon
admitted yesterday evening for sta- patient report above:
bilization of his uncontrolled type
II diabetes. He is married, and his Acute discomfort False
wife is requesting to stay at his side.
Alteration in comfort False
His HbgA1c is 10.6%. He has a his-
tory of a Myocardial Infarction, MI,
Knowledge Deficit True
one year ago, and has refused all
cardiac rehab, and has not had an- Nausea False
other cardiac event. He refuses to
comply with dietary recommenda- Potential for falls False
tions. His BMI is 37. Vital signs are:
BP: 146/94, P: 88, R: 22, T: 99.2, Potential for infection True
PaO2: 94% Blood glucose upon ad-
mission is 340 mg/dl
, Swift River- ATI
Study online at https://quizlet.com/_cdg679
4. Estelle Hatcher Select appropriate nursing concerns below based upon
patient report above:
Estelle Hatcher 31yr-old, r/o appen-
dicitis, 1st day post-op appendecto- Physiological
my; No known allergies (NKA); Vital Acute discomfort False
signs - Temp 101.2, BP 108/74, P 92, Alteration in bowel elimination: diarrhea: false
RR 20, SaO2 99%, alert and coop- Alteration in comfort: true
erative. Wound site clean, dry and Alteration in mobility: true
intact NPO, NG-tube to low contin- Decreased activity tolerance: false
uous suction. IV maintenance flu- Potential for alteration in electrolyte balance: true
ids with D5 1/2 NS with 20 KCL
@ 125ml/hr in left forearm. Ambu- Safety
lates with minimal assistance. Fam- Fear: false
ily at beside. Dr. Sangerstien Ineffectual self-health management: false
Knowledge deficit: true
Potential for falls: true
Potential for infection: true
Sleep deficit: false
5. Tom Richardson 46yr-old. Dx- uri- Select appropriate nursing concerns below based upon
nary stones with 3 episodes/5yrs. patient report above:
Allergic to sulfa drugs. Vital signs
-Temp 98.4,BP 175/105, P 112, RR Physiological
28, SaO2 94%; Neuro- WNL's. Skin
Acute discomfort: T
warm and pale. Generalized weak-
Alteration in nutrition: F
ness, blood tinged urine and severe
Alteration in urinary elimination: T
pain upon urination, GI- n/v. Clear
Electrolyte Imbalance: F
liquid diet. Strict I&O and strain all
Potential for alteration in mobility: T
urine, filters in bathroom. Patient
Potential for alteration in skin integrity: F
demonstrates urine strain proce-
dure. Severe pain (10/10) medicat-
Safety
ed q 30 minutes x4 with IV Mor-
, Swift River- ATI
Study online at https://quizlet.com/_cdg679
phine 2mg with little relief. IV D5 Potential for falls: T
1/2 NS @100ml/hr. Dr. Small at Sleep deficit: T
bedside with patient and family.
Stat lithotripsy treatment ordered.
Awaiting transport.
6. Sarah Getts 77 yr-old, Dx- Chron- Select appropriate nursing concerns below based upon
ic Renal Failure, admitted with patient report above:
hyperkalemia (5.9, Eq/L)/hypona-
tremia (128mEq/L). No known al- Physiological
lergies (NKA). Vital signs -Temp
Acute discomfort F
98.8, BP 102/76, P 102- irregular,
Decrease in fluid volume F
RR 22, SaO2 90%, cardiovascular
Electrolyte Imbalance T
on telemetry with Sinus irregular
Ineffectual renal perfusion, risk for T
rhythm. Disoriented to time and
Potential for alteration in skin integrity: F
place, speech slurred. Pupils PER-
Potential for imbalanced fluid volume: T
RLA, eyes clear. 20 ga. Hep-Lock in
right forearm, skin warm and dry,
Safety
generalized weakness with recent
weight loss. 50% intake. High fall Acute Confusion: T
risk. Renal diet. Family in room with Disturbed Sensory Perception: F
patient very concerned. Dr. Brown Potential for falls: T
Sleep deficit F
Love and belonging
Anxiety: F
Failure to Thrive: T
7. Sarah Kathryn Horton 25 -year old Select appropriate nursing concerns below based upon
graduate student was brought to patient report above:
the emergency room via ambu-
Study online at https://quizlet.com/_cdg679
1. Arthur Thomason 56-year-old MVA Alteration in comfort: True
victim, fourth day post op with a Alteration in gas exchange: True
splenectomy and femur repair. He Ineffectual airway clearance: True
is experiencing new onset of short- Potential for shock: True
ness of breath and has a nasal can- Prolonged confusion: True
nula with 2L of Oxygen in place. Anxiety/fear: True
He is restless with slight confu- Potential for failure to thrive: True
sion but is easily orientated with
attempts from nurse. Temperature
spiked during the night to 102.4,
BP now 146/94 which is slightly el-
evated, respirations at 30 bpm and
slightly labored, heart rate 102 ver-
sus 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 inter-
stitial infiltrates in all lobes. Recent
blood gases demonstrate falling
PaO2 (hypoxemia) and increasing
CO2 (Hypercapnia). Mr. Thomason
is anxious and is obviously wors-
ened from the shift before in over-
all condition.
2. Charlie Raymond 65-year-old male Acute discomfort False
who was admitted to a negative
pressure room on Med-Surg for Alteration in body image False
COVID precautions.. He has a histo-
Alteration in gas exchange True
ry of COPD, hypertension, diabetes
type II, and a recent myocardial in-
, Swift River- ATI
Study online at https://quizlet.com/_cdg679
farction. He is a retired postal work- Alteration in physical mobility True
er who lives at home with his wife.
He is on Claforan (cefotaxime) 2 g Alteration in skin integrity False
IV q4hr and sliding scale insulin.
.Bleeding False
Initially this cardiologist was con-
cerned about congestive heart fail-
Death anxiety True
ure and Mr. Raymond is receiving
Furosemide (Lasix) 20 mg IV twice Esteem False
a day for pulmonary edema. Vital
Signs: BP is 145/78, Pulse 89 Res- .Ineffectual breathing pattern True
pirations 24 and slightly labored,
Temperature 100.2 SaO2 94% on 2L Knowledge deficit True
nasal cannula. The patient/family is
fearing the worst due to COVID-19 Sudden confusion False
Pandemic.
3. Donald Lyles 52-year old male, was Select appropriate nursing concerns below based upon
admitted yesterday evening for sta- patient report above:
bilization of his uncontrolled type
II diabetes. He is married, and his Acute discomfort False
wife is requesting to stay at his side.
Alteration in comfort False
His HbgA1c is 10.6%. He has a his-
tory of a Myocardial Infarction, MI,
Knowledge Deficit True
one year ago, and has refused all
cardiac rehab, and has not had an- Nausea False
other cardiac event. He refuses to
comply with dietary recommenda- Potential for falls False
tions. His BMI is 37. Vital signs are:
BP: 146/94, P: 88, R: 22, T: 99.2, Potential for infection True
PaO2: 94% Blood glucose upon ad-
mission is 340 mg/dl
, Swift River- ATI
Study online at https://quizlet.com/_cdg679
4. Estelle Hatcher Select appropriate nursing concerns below based upon
patient report above:
Estelle Hatcher 31yr-old, r/o appen-
dicitis, 1st day post-op appendecto- Physiological
my; No known allergies (NKA); Vital Acute discomfort False
signs - Temp 101.2, BP 108/74, P 92, Alteration in bowel elimination: diarrhea: false
RR 20, SaO2 99%, alert and coop- Alteration in comfort: true
erative. Wound site clean, dry and Alteration in mobility: true
intact NPO, NG-tube to low contin- Decreased activity tolerance: false
uous suction. IV maintenance flu- Potential for alteration in electrolyte balance: true
ids with D5 1/2 NS with 20 KCL
@ 125ml/hr in left forearm. Ambu- Safety
lates with minimal assistance. Fam- Fear: false
ily at beside. Dr. Sangerstien Ineffectual self-health management: false
Knowledge deficit: true
Potential for falls: true
Potential for infection: true
Sleep deficit: false
5. Tom Richardson 46yr-old. Dx- uri- Select appropriate nursing concerns below based upon
nary stones with 3 episodes/5yrs. patient report above:
Allergic to sulfa drugs. Vital signs
-Temp 98.4,BP 175/105, P 112, RR Physiological
28, SaO2 94%; Neuro- WNL's. Skin
Acute discomfort: T
warm and pale. Generalized weak-
Alteration in nutrition: F
ness, blood tinged urine and severe
Alteration in urinary elimination: T
pain upon urination, GI- n/v. Clear
Electrolyte Imbalance: F
liquid diet. Strict I&O and strain all
Potential for alteration in mobility: T
urine, filters in bathroom. Patient
Potential for alteration in skin integrity: F
demonstrates urine strain proce-
dure. Severe pain (10/10) medicat-
Safety
ed q 30 minutes x4 with IV Mor-
, Swift River- ATI
Study online at https://quizlet.com/_cdg679
phine 2mg with little relief. IV D5 Potential for falls: T
1/2 NS @100ml/hr. Dr. Small at Sleep deficit: T
bedside with patient and family.
Stat lithotripsy treatment ordered.
Awaiting transport.
6. Sarah Getts 77 yr-old, Dx- Chron- Select appropriate nursing concerns below based upon
ic Renal Failure, admitted with patient report above:
hyperkalemia (5.9, Eq/L)/hypona-
tremia (128mEq/L). No known al- Physiological
lergies (NKA). Vital signs -Temp
Acute discomfort F
98.8, BP 102/76, P 102- irregular,
Decrease in fluid volume F
RR 22, SaO2 90%, cardiovascular
Electrolyte Imbalance T
on telemetry with Sinus irregular
Ineffectual renal perfusion, risk for T
rhythm. Disoriented to time and
Potential for alteration in skin integrity: F
place, speech slurred. Pupils PER-
Potential for imbalanced fluid volume: T
RLA, eyes clear. 20 ga. Hep-Lock in
right forearm, skin warm and dry,
Safety
generalized weakness with recent
weight loss. 50% intake. High fall Acute Confusion: T
risk. Renal diet. Family in room with Disturbed Sensory Perception: F
patient very concerned. Dr. Brown Potential for falls: T
Sleep deficit F
Love and belonging
Anxiety: F
Failure to Thrive: T
7. Sarah Kathryn Horton 25 -year old Select appropriate nursing concerns below based upon
graduate student was brought to patient report above:
the emergency room via ambu-
