ATI SWIFT RIVER Simulations 2.0
Answer keys with Client Report Sheet and Interruptions answers
Sarah Getts
Diagnosis: chronic kidney disease
DOB: 3/14/1967
MRN: 73918250
Room: 102
0645
Sarah Getts, age 58, was just admitted from the emergency department. The client came into the
ED reporting a 48 hr history of shortness of breath, headache, and nausea. The report not being
able to eat due to nausea and have been attempting to drink soda to keep from dehydrating.
The client is oriented X 4, has sinus tachycardia on the ECG monitor, and has breath sounds with
crackles bilaterally. The client states they are voiding cloudy urine.
History includes type I diabetes mellitus since age 8, insulin dependent; hypertension; and
kidney disease for the past 10 years.
Admission vital signs are: temperature 38.3° C (99° F), heart rate 116/min, respiratory rate
28/min, blood pressure 176/94 mmHg, and SpO2 95% on room air.
Labs were drawn in the ED but have not been recelved yet. The cllent is admitted to nephrology,
Dr. O'Gorman.
There are no prescriptions yet.
1. After receiving handoff report, the nurse should determine the client's priority needs.
Indicate if the client is a high priority or low priority using each of the priority
frameworks below.
Maslow's Hierarchy of Needs: High Priority
Airway, Breathing, Circulation: Low Priority
Safety and Risk Reduction: High Priority
Urgent vs Nonurgent: High Priority
Chronic vs Acute/Stable vs Unstable: High Priority
Initial Nursing Assessment
0745: The nurse reviews the information received in report.
2. Which of the following concerns should the nurse address while providing client care?
(Select all that apply.)
Select:
, Physiological: Comfort
Physiological: Nutrition
Physiological: Metabolism
Physiological: Gas Exchange
Physiological: Elimination
Physiological: Acid Base
0800: The nurse enters the client's room, obtains vital signs, and performs an assessment.
Current vital signs are:
Temperature 38.3° C (99° F)
Heart rate 118/min
Respiratory rate 28/min
Blood pressure 175/95 mmHg
SpO2 95% on room air
Neurological: The client is oriented to person, place, time, and circumstance. They answer
questions appropriately, moves all extremities, and follows simple commands. The client appears
fatigued with muscle weakness.
Integumentary: The skin is dry and flaky with bruising and ecchymosis on extremities. The client
reports pruritis.
Cardiovascular: Apical pulse is regular and rapid, rate of 118, sinus tachycardia with occasional
PVCs on ECG monitor. Pedal pulses are palpable bilaterally, edema present to lower extremities.
The client reports neuropathy to feet.
Respiratory: Breath sounds with bilateral crackles, tachypnea, respiratory rate of 28/min, and
reports frequent productive cough with thick sputum.
Gastrointestinal: Bowel sounds are active in all four quadrants. The client denies diarrhea, with
last bowel movement yesterday. They report anorexia due to nausea and "metallic taste in my
mouth." Genitourinary: Dark, cloudy urine is found in collection container. The client denies
pain with urination and reports decreasing urinary output over past 48 hr.
3. Which of the following client assessment findings require follow-up? (Select all that
apply.)
Select:
Heart rate and rhythm
Respiratory assessment
Urinary output
Nutritional status
0900: The nurse is reviewing the client's laboratory findings.
Complete Blood Count:
White Blood Cell Count: 6,500/mm3 (5,000 to 10,000/mm3)
Hemoglobin: 10 g/dL (12 g/dL to 16 g/dL)
Hematocrit: 28% (37% to 47%)
, Platelet Count: 120,000/mm3 (150,000 to 400,000/mm3)
Basic Metabolic Profile (BMP):
Sodium: 149 mEq/L ( 136 to 145 mEq/L)
Potassium: 5.2 mEq/L (3.5 to 5 mEq/L)
Glucose: 102 mg/dL (74 mg/dL to 106 mg/dL)
BUN: 35 mg/dL (10 mg/dL to 20 mg/dL)
Creatinine: 2.8 mg/dL (0.5 mg/dL to 1 mg/dL)
4. Which of the following laboratory values should the nurse report to the provider
immediately? (Select all that apply.)
Select:
Hemoglobin and hematocrit (H & H)
Sodium
Potassium
BUN
Creatinine
1000: The nurse reports the assessment and laboratory findings to the provider.
5. Which of the following prescriptions should the nurse anticipate from the provider?
(Select all that apply.)
Laboratory test: arterial blood gases (ABGs)
Diuretic supplementation
Chest x-ray
Daily weight
Laboratory test: estimated glomerular filtration rate (eGFR)
Measuring fluid intake and output (I & O)
1300: The nurse reviews the latest diagnostic information in the client's medical record.
eGFR: 18 mL/min/1.73 m2 (greater than 60 mL/min/1.73 m2)
Lateral decubitus chest x-ray: Mild opacity outside of lung fields indicative of pleural effusions
Arterial Blood Gases (ABGs):
pH: 7.30 (7.35 to 7.45)
Pco2: 32 mmHg (35 to 45 mmHg)
Hco3: 20 mEq/L (22 to 26 mEq/L)
Po2: 85 mmHg (80 to 100 mmHg)
6. The nurse is modifying the client's plan of care based on the latest diagnostic findings.
Which of the following additional concerns should the nurse address? (Select all that
apply.)
Answer keys with Client Report Sheet and Interruptions answers
Sarah Getts
Diagnosis: chronic kidney disease
DOB: 3/14/1967
MRN: 73918250
Room: 102
0645
Sarah Getts, age 58, was just admitted from the emergency department. The client came into the
ED reporting a 48 hr history of shortness of breath, headache, and nausea. The report not being
able to eat due to nausea and have been attempting to drink soda to keep from dehydrating.
The client is oriented X 4, has sinus tachycardia on the ECG monitor, and has breath sounds with
crackles bilaterally. The client states they are voiding cloudy urine.
History includes type I diabetes mellitus since age 8, insulin dependent; hypertension; and
kidney disease for the past 10 years.
Admission vital signs are: temperature 38.3° C (99° F), heart rate 116/min, respiratory rate
28/min, blood pressure 176/94 mmHg, and SpO2 95% on room air.
Labs were drawn in the ED but have not been recelved yet. The cllent is admitted to nephrology,
Dr. O'Gorman.
There are no prescriptions yet.
1. After receiving handoff report, the nurse should determine the client's priority needs.
Indicate if the client is a high priority or low priority using each of the priority
frameworks below.
Maslow's Hierarchy of Needs: High Priority
Airway, Breathing, Circulation: Low Priority
Safety and Risk Reduction: High Priority
Urgent vs Nonurgent: High Priority
Chronic vs Acute/Stable vs Unstable: High Priority
Initial Nursing Assessment
0745: The nurse reviews the information received in report.
2. Which of the following concerns should the nurse address while providing client care?
(Select all that apply.)
Select:
, Physiological: Comfort
Physiological: Nutrition
Physiological: Metabolism
Physiological: Gas Exchange
Physiological: Elimination
Physiological: Acid Base
0800: The nurse enters the client's room, obtains vital signs, and performs an assessment.
Current vital signs are:
Temperature 38.3° C (99° F)
Heart rate 118/min
Respiratory rate 28/min
Blood pressure 175/95 mmHg
SpO2 95% on room air
Neurological: The client is oriented to person, place, time, and circumstance. They answer
questions appropriately, moves all extremities, and follows simple commands. The client appears
fatigued with muscle weakness.
Integumentary: The skin is dry and flaky with bruising and ecchymosis on extremities. The client
reports pruritis.
Cardiovascular: Apical pulse is regular and rapid, rate of 118, sinus tachycardia with occasional
PVCs on ECG monitor. Pedal pulses are palpable bilaterally, edema present to lower extremities.
The client reports neuropathy to feet.
Respiratory: Breath sounds with bilateral crackles, tachypnea, respiratory rate of 28/min, and
reports frequent productive cough with thick sputum.
Gastrointestinal: Bowel sounds are active in all four quadrants. The client denies diarrhea, with
last bowel movement yesterday. They report anorexia due to nausea and "metallic taste in my
mouth." Genitourinary: Dark, cloudy urine is found in collection container. The client denies
pain with urination and reports decreasing urinary output over past 48 hr.
3. Which of the following client assessment findings require follow-up? (Select all that
apply.)
Select:
Heart rate and rhythm
Respiratory assessment
Urinary output
Nutritional status
0900: The nurse is reviewing the client's laboratory findings.
Complete Blood Count:
White Blood Cell Count: 6,500/mm3 (5,000 to 10,000/mm3)
Hemoglobin: 10 g/dL (12 g/dL to 16 g/dL)
Hematocrit: 28% (37% to 47%)
, Platelet Count: 120,000/mm3 (150,000 to 400,000/mm3)
Basic Metabolic Profile (BMP):
Sodium: 149 mEq/L ( 136 to 145 mEq/L)
Potassium: 5.2 mEq/L (3.5 to 5 mEq/L)
Glucose: 102 mg/dL (74 mg/dL to 106 mg/dL)
BUN: 35 mg/dL (10 mg/dL to 20 mg/dL)
Creatinine: 2.8 mg/dL (0.5 mg/dL to 1 mg/dL)
4. Which of the following laboratory values should the nurse report to the provider
immediately? (Select all that apply.)
Select:
Hemoglobin and hematocrit (H & H)
Sodium
Potassium
BUN
Creatinine
1000: The nurse reports the assessment and laboratory findings to the provider.
5. Which of the following prescriptions should the nurse anticipate from the provider?
(Select all that apply.)
Laboratory test: arterial blood gases (ABGs)
Diuretic supplementation
Chest x-ray
Daily weight
Laboratory test: estimated glomerular filtration rate (eGFR)
Measuring fluid intake and output (I & O)
1300: The nurse reviews the latest diagnostic information in the client's medical record.
eGFR: 18 mL/min/1.73 m2 (greater than 60 mL/min/1.73 m2)
Lateral decubitus chest x-ray: Mild opacity outside of lung fields indicative of pleural effusions
Arterial Blood Gases (ABGs):
pH: 7.30 (7.35 to 7.45)
Pco2: 32 mmHg (35 to 45 mmHg)
Hco3: 20 mEq/L (22 to 26 mEq/L)
Po2: 85 mmHg (80 to 100 mmHg)
6. The nurse is modifying the client's plan of care based on the latest diagnostic findings.
Which of the following additional concerns should the nurse address? (Select all that
apply.)
