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    ATI LPN Comprehensive Predictor 2023 Proctored Exam 3
    Select All That Apply

    A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Nurses' Notes 1500: The client is restless and is not following commands. The client does not tolerate lying flat. Skin warm and dry. Regular heart sounds without murmur. Respirations labored. Breath sounds with the right-sidedcrackles and wheezes in the posterior lower lobe. Abdomen soft, nondistended with positive bowel sounds in all four quadrants. Tremors in hands. Admission Assessment 1400: The client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, the client reported "feeling bad." The client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum. Select the 3 findings that require immediate follow-up.

    Explanation & Rationale

    A. Oxygen saturation level: The client is restless, not following commands, and has labored respirations with crackles and wheezes in the breath sounds. Monitoring the oxygen saturation level is essential to assess the client's respiratory status and oxygenation. B. Tremors: The client has tremors in their hands. Considering the client's history of Parkinson's disease, changes in tremors should be monitored and addressed promptly. C. The immediate concern is addressing the respiratory distress. D. Heart rate may also be monitored, but it's not as critical in this context. E. Chronic health conditions are relevant for the overall care plan, but they do not require immediate intervention as compared to respiratory and tremor issues. F. Respiratory rate: The client has labored respirations and abnormal breath sounds (crackles and wheezes). Monitoring the respiratory rate is important to evaluate the client's breathing pattern and respiratory distress.

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