Practice Question
A nurse is caring for a client on the medical-surgical unit.
Answer Choices:
Rationale:
🔴 Diaphoretic, agitated
🔻 These signs suggest increased sympathetic response, which may occur during a pulmonary embolism or respiratory compromise.
🔻 Acute changes in mental status and behavior warrant immediate follow-up.
🔻 These could indicate a worsening oxygenation issue or cardiac strain.
🔴 Bilateral crackles
🟡 Crackles reflect fluid in the alveoli, often seen in congestive heart failure, pulmonary embolism, or other causes of impaired gas exchange.
🟡 This is a significant change from previous faint wheezing and requires urgent respiratory assessment.
🔴 Respiratory rate 24/min
🔷 Tachypnea is a compensatory response to impaired oxygenation or acid-base imbalance.
🔷 This rate, along with crackles and low SpO₂ trends, supports a developing complication, like a PE.
🔴 Heart rate 111/min
🟢 Tachycardia in a post-op patient with respiratory symptoms could indicate hypoxemia, sepsis, or a thromboembolic event.
🟢 It is especially concerning in a client with immobility and risk factors such as COPD and obesity.
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This question is from RN ATI Comprehensive Predictor-2023~2025 which contains 185 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI EXIT Exam(s)
- Domain: RN ATI Comprehensive Predictor Exam(s)~2025
- Answer Choices: 1