AND VERIFIED ANSWERS WELL GRADED BEST ATI
1. A nurse in a medical-surgical unit is caring for six clients.
Complete the following sentence by using the list of options.
The first client the nurse should assess is followed by .
Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.
Client2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO adminis-
tered as prescribed.
Client 3: Client is 1 day postoperative. Reports pain as
8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as pre- scribed.
Client 4: Client is admitted with a new diagnosis of heart failure.
Client5: Client has a stage 2 pressure injury on the left heel.
Client 6: Client is admitted with a new diagnosis of diabetes mellitus.:
Answer : (1):
Client 3
When using the airway, breathing, circulation approach to client care, the
nurse should determine that this client is the priority client to assess. The
client has an oxygen saturation that is less than the expected reference
range, which is an indication of hypoxia.
Answer : (2):
,Client 4
When using the airway, breathing, circulation approach to client care, the nurse
should determine that this client is the next priority client to assess. The client
hasa potassium level that is less than the expected reference range, which places
theclient at risk for dysrhythmias.
In
Answer : (1):
Client 1 is incorrect. The nurse should assess this client because the client's C-re-
active protein is greater than the expected reference range, which is an indication
of inflammation. However, there is another client the nurse should assess first.
Client 2 is incorrect. The nurse should assess this client because the client's
cholesterol level is greater than the expected reference range, which places them
at risk for coronary heart disease. However, there is another client the nurse
shouldassess first.
In
Answer : (2):
Client 5 is incorrect. The nurse should assess this client because their prealbumin
level is less than the expected reference range, which places them at risk for delayed
wound healing. However, this client is not the next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated
hemoglobin level is greater than the expected reference range, which indicates
poor diabetic control. However, this client is not the next priority client to assess.
,2. A nurse is caring for a client who has COPD.
Select the 3 findings that require follow-up.
Breath sounds
Blood pressure
Oxygen saturation
Temperature
Heart rate:
Answer : :
Breath Sounds
Crackles are caused by mucous in the airways and are a manifestation of pneumo-
nia. Decreased breath sounds indicate decreased ventilation and require follow-up
by the nurse.
Oxygen Saturation
The client's oxygen saturation is below the expected reference range of 95%
to 100%, indicating hypoxia, and requires follow-up by the nurse.
Temperature
The client's temperature is greater than the expected reference range, indicating an
infection, and requires follow-up by the nurse.
In
Answer : :
Blood pressure is incorrect. The client's blood pressure is within the
expectedreference range and does not require follow-up by the nurse.
, Heart rate is incorrect. The client's heart rate is within the expected reference
rangeof 60 to 100/min and does not require follow-up by the nurse.
3. A nurse in the emergency department (ED) is caring for a client who
reports abdominal pain.
Based on the client's clinical findings, which of the following actions shouldthe
nurse take? Select all that apply.