ATI RN 3.0 Clinical Judgment Practice 1 Study Guide 2024/2025

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 Methylp - ANSWERSAssist 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 - ANSWERSLiver 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 Heart rate 96/min Respiratory rate 28/min Temperature 37.3° C (99.1° F) 2/15/XX: Blood pressure 124/78 mm Hg Heart rate 86/min Respiratory rate 20/min Temperature 37.3° C (99.1° F) Laboratory Results 01/15/XX: Fasting blood glucose 102 mg/dL (74 to 106 mg/dL) LDL 150 mg/dL (less than 130 mg/dL) HbA1c 7.9% (less than 7%) PaCO2 47 mm Hg (35 to 45 mm Hg) 02/15/XX: Fasting blood glucose 120 mg/dL (74 to 106 mg/dL) LDL 125 mg/dL (less than 130 mg/dL) HbA1c 9.2% (less than 7%) PaCO2 48 mm Hg (35 to 45 mm Hg) Physical Examination 01/15/XX: Height 162.5 cm (64 in) Weight 100 kg (221 lb) Client reports smoking two packs of cigarettes each day. Inspiratory wheezes in bilateral upper lobes on auscultation Erect posture Slow, purposeful ga - ANSWERSHbA1c - Indication of worsening condition Blood Pressure - Indication of improving condition Lung Sounds - No change in condition Blood Glucose - Indication of worsening condition Weight - Indication of worsening condition LDL - Indication of improving condition A nurse is caring for a client in a clinic. Nurses Notes 2/1/XX: Weight: 77.3 kg (170.1 lb) Client presented to the clinic with reports of frequent headaches, stomach cramps, and diarrhea. Client reports issues with marriage but is attending counseling with spouse. Education given on new prescription citalopram. 3/1/XX: Weight: 71.1 kg (156.4 lb) Client presented to the clinic for follow up. Client reports continued headaches, stomach cramps, and diarrhea. Client states that it is difficult to take this medication daily. Client reports that their relationship has ended. Client states, "I am so sad and lonely. I never thought I would have to endure such pain. I don't know how I am going to go on." Client reports feeling exhausted during the day but unable to sleep through the night as well as difficulty concentrating at work. Vital Signs 2/1/XX: Temperature 36.7° C (98° F) Heart rate 86/min Respiratory rate 16/ - ANSWERSMedication regime Sleep patterns Reports of helplessness Weight A nurse is caring for a school-age child who is newly admitted to the facility. Physical Examination 0900: Weight: 20.5 kg (45.1 lb) Height: 120 cm (3 feet 11 in) Cardiac: Heart beat regular, no murmur Clubbing of fingers and toes with cyanosis Respiratory: Coarse crackles bilaterally, short of breath, tripod positioning, cough noted with yellow sputum Gastrointestinal: Abdomen soft and nontender, positive bowel sounds in all quadrant, steatorrhea noted Genitourinary: Voiding spontaneously Eyes: Pupils equal and reactive to light; strabismus noted to the left eye Nurses Notes 0900: Guardian reports child is "less energetic than normal, has a decreased appetite, and has lost 3 pounds in the past 5 days." Vital Signs 0900: Temperature 37.5° C (99.5° F) Pulse rate 120/min Respiratory rate 32/min BP 100/66 mm Hg Oxygen saturation 88% room air 1000: Temperature 38.4° C (101.1° F) Pulse rate 110/min Respiratory r - ANSWERSOxygen saturation levels - Asthma, Cystic Fibrosis, Bacterial Pneumonia Respiratory rate - Asthma, Cystic Fibrosis, Bacterial Pneumonia Clubbing fingers - Cystic Fibrosis Heart rate - Asthma, Cystic Fibrosis, Bacterial Pneumonia Lung sounds - Asthma, Cystic Fibrosis, Bacterial Pneumonia Chest x-ray results - Cystic Fibrosis, Bacterial Pneumonia WBC level - Cystic Fibrosis, Bacterial Pneumonia When analyzing cues, the nurse should recognize that an elevated WBC, a chest x-ray that shows bilateral infiltrate and lobar consolidation, tachycardia, clubbing of fingers, lung sounds with coarse rhonchi bilaterally, tachypnea, and low oxygen saturations are clinical manifestations of a client who has cystic fibrosis and has a current infection, quite often Peudomonas pneumonia. A client who has bacterial pneumonia will exhibit all of the same clinical manifestations because Pseudomonas pneumonia is a bacterial infection. However, because bacterial pneumonia is acute, the client will not have clubbing of fingers. A client who has asthma presents with tachycardia, course crackles and wheezing, tachypnea, and low oxygen saturation due to acute bronchoconstriction and inflammation in the lungs. A nurse in a clinic is caring for an infant at the 6-month well child visit. Medical History Infant was born at 40 weeks of gestation with a myelomeningocele. Surgical repair of the defect occurred at 1 day old without complications. Progressive hydrocephalus was noted and a ventriculoperitoneal (VP) shunt was placed at 2 months of age. Vital Signs 4-month well-child visit: Temperature 37.1° C (98.8° F) tympanic Heart rate 120/min Respiratory rate 25/min 6-month well-child visit: Temperature 36.8° C (98.2° F) tympanic Heart rate 142/min Respiratory rate 28/min Physical Examination 4-month well-child visit: Anterior fontanel is flat and firm Head circumference 16.3 cm (6.4 in) VP shunt line is palpable on scalp Apical pulse is regular Respirations are unlabored 6-month well-child visit: Anterior fontanel is raised and bulging on palpation Head circumference 21.3 cm (8.4 in) VP shunt line is palpa - ANSWERSThe client is at highest risk for developing brain damage as evidenced by the client's VP shunt malfunction A nurse on a medical surgical floor is caring for a newly admitted client following a motor vehicle accident. Medication Administration Record Day 1: Hydrocodone/acetaminophen 5 mg every 4 hr PRN pain History and Physical Day 1: Client is hospitalized following a motor vehicle crash. Client lost consciousness for approximately 30 min following the crash. Client is not oriented to place or time. Follows commands. Multiple bruises noted on client's upper and lower extremities and petechia noted on lower legs. Client reports pain as 2 on a scale of 0 to 10. Day 2: Client is orientated to place and time. Client has slurred speech, poor coordination, and impaired thinking. Client reports nausea, vomiting, and appears agitated. Client is diaphoretic. Client reports pain as 4 on a scale of 0 to 10. Diagnostic Results Day 1: Platelet count 80,000/mm3 (150,000 to 400,000/mm3) WBC count 4,000/mm3 (5,000 to 10,000/mm3) A - ANSWERSThe nurse should first address the client's agitation followed by the client's blood pressure