NUR105 M6.6: ATI- Real Life RN Medical Surgical 4.0: Urinary Tract Infection
What additional information would assist Nurse Craig in preparing to care for Mrs. Jordan? List 5 additional pieces of information that should have been included in the report.NUR105 M6.6: ATI
Additional information that would assist Nurse Craig in preparing to care for Mrs. Jordan should include:
The amount and timing of Levofloxacin (Levaquin) administered and the schedule for the next dose.
Clarification about the client’s baseline level of agitation and if it’s worsening. Information on how the client’s tiredness was determined.
Confirmation of a probable discharge within the next 24 hours, including any discharge orders or plans.
Details about the client’s urinary output, including the amount, color, and characteristics of urine.
Information regarding the type and amount of IV solution administered in the emergency department, the current IV solution type and rate, IV site location, and catheter size.
Nurse Craig is assessing Mrs. Jordan. Which of the following actions should the nurse take next?
Nurse Craig should apply oxygen per nasal cannula at 2 L/min.
Nurse Craig observes that Mrs. Jordan is restless and having increased difficulty breathing. Which of the following assessments is appropriate for Mrs. Jordan’s needs at this time?
A rapid focused assessment is appropriate for Mrs. Jordan’s needs at this time.NUR105 M6.6: ATI
Based on the findings from the rapid focused assessment, which of the following actions should Nurse Craig perform first?
Nurse Craig should increase oxygen to 4 L/min.
Nurse Craig has received a bag of medications from Mrs. Jordan’s home. He reviews each of the medications. Which of the following is the best action for Nurse Craig to take at this time?
Nurse Craig’s best action is to request medication reconciliation with the pharmacy.
Nurse Craig has reviewed Mrs. Jordan’s medications received from her home. Nurse Craig labels the medication bag and locks the medications in a cabinet. Based on events so far, which of the following best describes Mrs. Jordan’s priority underlying medical condition?
Based on the events, Mrs. Jordan’s priority underlying medical condition appears to be cardiac.
Mrs. Jordan has experienced increased respiratory distress during the past 2 hr. Since admission, she has received 2,550 mL IV and 100 mL orally. Her urinary output since admission to the medical-surgical unit has been 100 mL. Which of the following clinical manifestations indicates exacerbation of heart failure and should be reported to the provider? (Select all that apply.)
The following clinical manifestations indicate exacerbation of heart failure and should be reported to the provider:
Dependent Pitting edema
Crackles in the lungs
The provider has just informed Mrs. Jordan that due to her cardiac condition she is not a candidate for surgery. Mrs. Jordan is tearful and has a frightened look on her face. Which of the following is an appropriate statement by Nurse Craig?
An appropriate statement by Nurse Craig would be, “Tell me about the concerns you have.”
Nurse Debbie is preparing to provide a bed bath for Mrs. Jordan, who is in Buck’s traction. Which of the following is the appropriate action for Nurse Debbie to take?
The appropriate action for Nurse Debbie is to leave the traction in place.
Mrs. Jordan is at risk for skin breakdown due to her age, her cardiac condition, and her mobility that is restricted due to the placement of Buck’s traction. Nurse Stephanie assesses the client for skin breakdown. Based on the photograph, Nurse Stephanie should classify the skin breakdown as which of the following?
Nurse Stephanie should classify the skin breakdown in the photograph as Stage 2.
Which of the following should Nurse Debbie include in the plan of care for Mrs. Jordan, who has a fractured hip and is in Buck’s traction?
Nurse Debbie should include monitoring Mrs. Jordan’s ability to move her toes on the affected leg in the plan of care.
Mrs. Jordan reports that she is short of breath. Her SaO2 is 85%, and the oxygen flow rate has been increased to 6 L/min. Nurse Debbie reassesses the client. Which of the following clinical findings is an early indicator of shock?
Restlessness is an early indicator of shock.
Nurse Debbie assessed Mrs. Jordan and determined that Mrs. Jordan is at risk for shock. Which of the following types of shock is Mrs. Jordan at risk for?
Mrs. Jordan is at risk for distributive shock.NUR105 M6.6: ATI
Nurse Debbie is reviewing the laboratory report. Which of the following arterial blood gases (ABGs) indicate that Mrs. Jordan is experiencing metabolic acidosis?NUR105 M6.6: ATI
An ABG result of pH 7.28, PaCO2 35, HCO3 20 indicates that Mrs. Jordan is experiencing metabolic acidosis.
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