ATI Comp Practice B W/NGN Exam 2024

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L ) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L ) Total calcium 8 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC 9,500/mm3 (5,000 to 10,000/mm3) Nurses' Notes 0700: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication. 1100: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. - The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips. A nurse is caring for a client who has abdominal pain. Nurses' Notes 0900: Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped country. 1200: Results of antibody studies obtained. Provider prescription for antiviral medication pending. Physical Examination 0930: Lung sounds clear bilaterally. Skin warm to touch and jaundiced. Dry skin noted on extremities. Sclera yellow bilaterally. Bowel sounds normoactive in four quadrants. Client reports right upper quadrant pain upon palpation. Urine specimen obtained for urinalysis, dark yellow in color. Vital Signs 0900: Temperature 36.9° C (98.5° F) Heart rate 84/min Respiratory rate 18/min Blood pressure 118/78 mm Hg Oxygen saturation 98% on room air Diagnostic Results 1100: Aspartate aminotra - Characteristic Hepatitis A: Laboratory results Physical examination findings Client's risk from fecal-oral transmission Hepatitis B: Laboratory results Antiviral treatment Client's risk from bloodborne transmission Physical examination findings Hepatitis C: Laboratory results Antiviral treatment Client's risk from bloodborne transmission Physical examination findings A nurse is caring for a client on a medical-surgical unit. Vital Signs 0700: Temperature 37.6° C (99.7° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 115/70 mm Hg Oxygen saturation 98% on room air Nurses' Notes 1100: Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr. - Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr. A nurse is caring for a client who is on the spinal cord injury (SCI) unit. Nurses' Notes Day 3, 1700: Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0 on a 0 to 10 scale. Day 4, 0600: Client reports increased coughing and shortness of breath. Crackles auscultated in lower lobes bilaterally. Face and neck flushed. Skin warm and moist. Client reports blurred vision and a headache as an 8 on a 0 to 10 pain scale. Abdomen soft and mildly distended. Hypoactive bowel sounds present. Urinary output 300 mL over last 8 hr. - The client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A nurse is caring for a client who is pregnant in the acute care setting. Nurses' Notes 1400: Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied. 1430: Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 150/min to 155/min, moderate variability, adequate accelerations present, no decelerations noted. Provider in to see client. Specimen obtained for fetal fibronectin. 1800: Client sleepy. Difficult to arouse. Respirations slow and shallow. Contraction pattern: contractions every 10 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 140/min, moderate variability, no accelerations present, no decelerations noted. Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 72/min Respiratory rate 20/min Blood - The nurse should first address the client's respiratory rate, followed by the client's level of consciousness. A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Vital Signs 1100: Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min Blood pressure 128/68 mm Hg Oxygen saturation 97% on room air 1115: Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min Blood pressure 138/74 mm Hg Pulse oximetry 95% on room air 1130: Temperature 38.6° C (101.5° F) Heart rate 136/min Respiratory rate 16/min Blood pressure 154/86 mm Hg Oxygen saturation 95% on 2 L/min via nasal cannula Medication Administration Record 1110: Morphine 4 mg IV bolus Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to 10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact. 1115: Client asleep. Arousable with name called loudly multiple times. Cl - Blood pressure Temperature Mental status Heart rate A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? - Inform the nurse manager of the issue. A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 10 kg (22 lb) and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - 0.6 A nurse on the medical-surgical unit is caring for a client who was admitted from the emergency department (ED). Vital Signs 1400: Temperature 38° C (100.4° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 96/58 mm Hg Oxygen saturation 96% on room air 1500: Temperature 37.2° C (98.9° F) Heart rate 96/min Respiratory rate 20/min Blood pressure 100/70 mm Hg Oxygen saturation 97% on room air Nurses' Notes 1500: Client admitted from the ED for dehydration. Client alert and oriented to person, place, and time. Client reports they are feeling "weak." IV dextrose 5% in water (D5W) infusing at 100 mL/hr. Laboratory Results 1400: Calcium 10.2 mg/dL (9 to 10.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Potassium 4.7 mEq/L (3.5 to 5 mEq/L) Sodium 150 mEq/L (136 to 145 mEq/L) 1700: Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Potassium 4.1 mEq/L (3.5 to 5 mEq/L) Sodium 164 - The client is at risk for developing confusion due to sodium level. A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Vital Signs Day 1, 2005: Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 23/min Blood pressure 90/55 mm Hg Oxygen saturation 98% on room air Day 2, 0800: Temperature 36.1° C (97° F) Heart rate 65/min Respiratory rate 20/min Blood pressure 88/57 mm Hg Oxygen saturation 98% on room air Graphic Record Day 1, 2005: Weight 37.5 kg (82.7 lb) Height 162.56 cm (64 in) BMI 14.2 Day 2, 0800: Weight 37.4 kg (82.5 lb) BMI 14.1 Laboratory Results Day 1, 2030: Sodium 146 mEq/L (136 to 145 mEq/L) Potassium 3.3 mEq/L (3.5 to 5 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL ) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Glucose (casual) 75 mg/dL (74 to 106 mg/dL) Total protein 5.8 g/dL (6.4 to 8.3 g/dL) Albumin 3 g/dL (3.5 to 5 g/dL) Day 2, 0530: Sodium 150 mEq/L (136 to 14 - The nurse should first address the client's electrolyte imbalance, followed by the client's fear of weight gain. A nurse is caring for a client. Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred. Vital Signs Day 1,1000: Temperature 37.2° C (99° F) Heart rate 114/min Blood pressure 184/88 mm Hg Respiratory rate 24/min Oxygen saturation 97% on 2 L via nasal - Anticipated: Keep the lights in the client's room dim. Monitor blood glucose every 4 hr. Administer oxygen therapy to keep oxygen saturation above 95%. Contraindicated: Keep the client supine. Cluster nursing care. Maintain the client's hips in flexion. A nurse is caring for an adolescent in the emergency department (ED). Nurses' Notes 0700: Adolescent admitted to ED. Adolescent's parents are concerned about left leg injury that appears to be getting worse. Parents report adolescent has had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715: Adolescent is alert and oriented to person, place, time, and situation. Adolescent reports left lower leg pain as 4 on a scale of 0 to 10. Heart rate regular. Capillary refill less than 3 seconds. Respirations even, unlabored. Lungs clear anterior/posterior. Abdomen soft, nondistended. Bowel sounds hyperactive in all 4 quadrants. Pedal pulses +2 bilaterally. Medial lateral aspect of left lower leg: 3 x 3 cm2 area of redness with small pustules present. Tenderness and warmth noted to the area. Vital Signs 0700: Temperature 38.7° C (101.7° F) - Skin assessment Temperature WBC count Casual blood glucose Potassium A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG). Laboratory Results 0630: Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L) Chloride 116 mEq/L (98 to 106 mEq/L) BUN 24 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3) I&O 0700: 4 hr input 400 mL4 hr output 350 mL 1100: 4 hr input 475 mL4 hr output 360 mL 1500: 4 hr input 350 mL4 hr output 375 mL Vital Signs 0700: Temperature 37.6° C (99.6° F) Heart rate 86/min Respiratory rate 20/min Blood pressure 115/70 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1100: Temperature 37.2° C (99° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 110/72 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1500: Temperat - The client is at greatest risk for developing dysrhythmias as evidenced by electrolyte imbalance. A nurse is caring for a client who is pregnant. Nurses' Notes 1000: The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks. 1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus. 1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine. 1500: Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine. Vital Signs 1000: Temperature 36.8° C (98.2° F) Heart rate 112/min Respiratory rate 20/min Blood pressure 100/65 mm Hg SaO2 97% on room air 1200: Temperature 37° C (98.6° F) Heart rate 102/min Respiratory rate 20/min Blood pressure 104/70 mm Hg SaO2 98% on room air 1500: Temperature 36.8° C (98.2° F) Heart rate 90/min Respiratory rate 18/min Bl - Recommended: Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Drink warm ginger ale when nauseated. Contraindicated: Increase intake of high-fat foods. A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? - "I will make sure my child receives a yearly influenza immunization." A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? - The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? - Upper chest petechiae A nurse is caring for an adolescent in the emergency department (ED). Laboratory Results Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Chloride 103 mEq/L (98 to 106 mEq/L) BUN 15 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL) Glucose 80 mg/dL (74 to 106 mg/dL) Total protein 7 g/dL (6.4 to 8.3 g/dL) Albumin 4.5 g/dL (3.5 to 5 g/dL) WBC count 19,500/mm3 (5,000 to 10,000/mm3) Aspartate aminotransferase (AST) 30 units/L (10 to 40 units/L) Alanine transaminase (ALT) 20 units/L (4 to 36 units/L) Diagnostic Results Cerebrospinal fluid examination Pressure: 35 cm H2O (less than 20 cm H2O) Color: Cloudy (clear and colorless) Blood: None RBC: 0 (0 cells) WBC total: 120 cells/μL (0 to 10 cells/μL) Protein: 90 mg/dL (15 to 45 mg/dL) Glucose: 20 mg/dL (50 to 75 mg/dL) Medication Administ - Bacterial Meningitis: fever photophobia nuchal rigidity petechial rash impaired consciousness Encephalitis: fever nuchal rigidity altered mental status Reye Syndrome: altered mental status impaired hepatic function. A nurse is caring for a client at a provider's office. History and Physical 2 months ago: Client presented to clinic for routine visit. Client reported feeling tired at times but getting through the workday and walking after work. Reported chronic nonproductive cough. Smokes 1.5 packs of cigarettes per day. Today, 1030: Client reports fatigue over the past several days, spending more time in bed. Reports chronic productive cough with blood-tinged sputum this morning. Smokes 1 pack of cigarettes per day. Client takes lisinopril 20 mg PO daily, atorvastatin 20 mg PO daily. Assessment 2 months ago: Client states, "I sleep in my recliner and that works great." Skin is warm, dry. Lungs clear to auscultation. Chronic nonproductive cough. Abdomen soft, nondistended. Bowel sounds present. Slight edema in feet bilaterally. Today, 1030: Client states, "I can't catch my breath." Skin pale. Respirations labored. Crackles prese - ENTER ANSWER A nurse is caring for a client following a laparoscopic cholecystectomy. Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to person, place, and time. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Client denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision intact upon inspection, no redness, swelling, or drainage noted. Client Education 1230: Discharge instructions given to client. Instructions on incision/wound care and proper hand washing. Client to report swelling, redness, drainage, bleeding, or warmth at operative site to surgeon. Client expected to experience carbon dioxide retention in the abdomen. Instructed the client to rest for 24 hr following surgery. Client can bathe or shower the day after - ENTER ANSWER A nurse is assessing a newborn who is 3 days old. History and Physical Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress. Apgar scores: 8 at 1 min and 9 at 5 min. Birth weight: 2.9 kg (6 lb 6 oz) The client who gave birth plans to breastfeed. Flow Sheet Day 2 of Life, 0900: Temperature 36.7° C (98.1° F) Heart rate 140/min Respiratory rate 48/min Weight 2.7 kg (6 lb); 6% weight loss Day 3 of Life, 0800: Temperature 36.4° C (97.5° F) Heart rate 140/min Respiratory rate 48/min Weight 2.5 kg (5 lb 9 oz); 12% weight loss Nurses' Notes Day 3 of Life, 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of bloody mucus discharge noted from vagina. Breastfeeding e - Temperature 36.4° C (97.5° F) Weight 2.5 kg (5 lb 9 oz); 12% weight loss Mild tremors noted when awake. Breastfeeding every 3 to 5 hr for 5 to 10 min. Client reports nipple discomfort throughout the feeding. A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation. Diagnostic Results WBC count 9,800/mm3 (5,000 to 10,000/mm3) Hgb 13 g/dL (greater than 11 g/dL) Hct 41% (greater than 33%) Platelet count 170,000/mm3 (150,000 to 400,000/mm3) BUN 20 mg/dL (10 to 20 mg/dL) Lactate dehydrogenase (LDH) 80 units/L (100 to 190 units/L) Aspartate aminotransferase (AST) 18 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 19 units/L (4 to 36 units/L) Uric acid (serum) 5.4 mg/dL (2.7 to 7.3 mg/dL) Kleihauer-Betke (fetal hemoglobin test) 3% (less than 1%) Blood type: ARh: positive Urine reagent strip Glucose: nonepH: 6 Specific gravity: 1.020 Ketones: none Nitrates: none Leukocyte esterase: negative Protein: negative Nitrites: none Vital Signs Blood pressure 130/84 mm Hg Heart rate 104/min Respiratory rate 22/min Temperature 37.3° C (99.2° F) Oxygen saturation 97% on room air Nurses' Notes Clien - Potential condition: Abruptio placentae Actions to take: Insert a large bore IV catheter Avoid cervical exam Parameters to monitor: Platelet count blood pressure When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? - Blowing bubbles with liquid soap to "blow the hurt away" A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/min Respiratory rate 26/min Blood pressure 88/56 mm Hg Oxygen saturation 90% on 2 L via nasal cannula Diagnostic Results 0645: Hematocrit 25% (37% to 52%) Hemoglobin 8.3 g/dL (12 to 16 g/dL) WBC count 18,000/mm3 (5,000 to 10,000/mm3) Reticulocytes 8% ( - Administer IV fluids Use humidification with oxygen therapy in correct Assess peripheral circulation hourly is correct Assess the client's mouth every 8 hr is correct A nurse in an outpatient mental health clinic is caring for a client Vital Signs 3 months ago: Blood pressure 116/68 mm Hg Heart rate 82/min Respiratory rate 16/min Temperature 36.7° C (98.1° F) SaO2 97% on room air Today: Blood pressure 128/76 mm Hg Heart rate 104/min Respiratory rate 22/min Temperature 37.4° C (99.4° F) SaO2 97% on room air Nurses' Notes 3 months ago: Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to questions. Client reports sleeping well and working at a local retail store. Today: Client presents for follow-up visit. Pressured speech noted. Appears to be listening to unseen others. Client is restless. Frequently getting out of chair. Appears tired and disheveled. Graphic Record 3 months ago: 83.9 kg (185 lb)Today: - Speech Auditory hallucinations Restlessness A nurse is caring for a 1-month-old infant. Nurses' Notes 1500: Infant admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive in all 4 quadrants. Small 1 x 1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600: Called to room by parent. The client who gave birth attempted breastfeeding. Infant projectile vomited. No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with pacifier. Diagnostic Results 1545: Hgb 20 g/dL (14 to 24 g/dL) Hct 60% (44% to 64%) Potassium 5.8 mEq/L (3.9 to 5.9 mEq/L) Sodium 132 mEq/L (134 to 150 mEq/L) Chloride 110 mEq/L (96 to 106 mEq/L) WBC - The infant is at highest risk for developing dehydration, as evidenced by the infant's vomiting. A nurse is caring for a client who is postoperative following an appendectomy. Nurses' Notes 1800: Client alert and oriented to person, place, time, and situation. Skin warm and dry. Lungs clear on auscultation Bowel sounds hypoactive in all four quadrants. Urine clear yellow Incisional dressing clean and dry. Client reports pain as 6 on a scale of 0 to 10. 1815: Morphine administered as prescribed. 2000: Client reports abdominal pain as 10 on a scale of 0 to 10. Client reports nausea, no vomiting. Incisional dressing is dry and intact with no breakthrough bleeding noted. Lung sounds are clear to auscultation. Hypoactive bowel sounds present in all four quadrants. Vital Signs 1800: Temperature 36.8° C (98.4° F) Heart rate 104/min Respiratory rate 22/min Blood pressure 142/80 mm Hg O2 saturation 97% on room air 2000: Temperature 36.8° C (98.4° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 158/88 - Pain level Heart rate o2 sat Nausea A nurse is caring for a 5-year-old child. Physical Examination 1510: Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds. Nurses' Notes 1500: Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and leaning forward with drooling noted. Vital Signs 1505: Axillary temperature 38.8° C (102° F) Heart rate 130/min Respiratory rate 28/min Blood pressure 99/58 mm Hg Oxygen saturation 90% on room air Medical History Family history of asthma Child seen 6 months ago for tonsillitis and treated with antibiotic therapy - Potential condition: Epiglottitis Actions to take: IV antibiotics Droplet precautions Parameters to monitor: Temp Breath sounds A nurse is caring for a client who is postoperative following administration of general anesthesia. Vital Signs 0830: Temperature 36.9° C (98.5° F) Heart rate 134/min Respiratory rate 28/min Blood pressure 92/52 mm Hg Oxygen saturation 89% on room air Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair. Apical pulse 134/min and irregular Client reports dyspnea. Diagnostic Results 0835: Arterial blood gases (ABGs) pH 7.30 (7.35 to 7.45) PCO2 64 mm Hg (35 to 45 mm Hg) HCO3- 26 mEq/L (21 to 28 mEq/L) PO2 80 mm Hg (80 to 100 mm Hg) - Potential condition: Malignant hyperthermia Actions to take: admin oxygen admin dantrolene Parameters to monitor: hypercapnia muscle rigidity A nurse in an emergency department (ED) is assessing a client. Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first- generation medication 6 months ago Current medications: Haloperidol 5 mg PO TID Sumatriptan 50 mg PO every 2 hr PRN headache Vital Signs 1030: Heart rate 122/min Respiratory rate 28/min Blood pressure 182/85 mm Hg Temperature 39.7° C (103.5° F) Oxygen saturation 90% on room air