HESI CASE STUDY – COPD with Pneumonia – Flashcards
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Which assessment is most important for the nurse to complete next?
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Auscultate breath sounds
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Which assessment finding supports Mr. Johnson's diagnosis of pneumonia?
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Pulse rate of 115
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Based on these ABG results, which acid base imabalance is Mr. Johnson experiencing?
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Respiratory acidosis
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Which nursing diagnosis has the highest priority when planning care for Mr. Johnson?
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Ineffective airway clearance
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Which nursing action should be implemented before administering the prescribed Unasyn?
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Obtain a sputum culture
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The ampicillin (Unasyn) 1 gm IVPB is supplied in 50mL of D5W to be delivered over 30min. The nurse should set the IV pump at how many mL per hour?
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100
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Which assessment is most important for the nurse to perform while Mr. Johnson is receiving Ventolin?
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Monitor pulse and BP
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After observing Mr. Johnson, what client teaching should the nurse initiate?
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Wait at least 1min between each puff of the same medication
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Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma
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Use the Ventolin inhaler for acute asthma attacks
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After checking the sensor site to make sure the readings are accurate, which intervention should the nurse initiate next?
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Elevate the head of the bed to a high-Fowler's position
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Which action should the nurse implement to ensure accurate oxygen saturation readings via a pulse oximeter?
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Assess adequacy of circulation prior to applying the sensor
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What is the best statement for the nurse to use to promote effective communication with Mr. Johnson?
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You seem pretty upset this morning
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What is the nurse's best response?
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Remain silent
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What is the BEST nursing action?
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Instruct the UAP involved regarding the inappropriate removal of the nasal cannula
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Which 1 of these rights was violated in that situation
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Right Direction/Communication
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Which intervention should the nurse initiate immediately?
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Place resuscitation equipment in the room
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What ethical principle is the most important for the nurse to consider when responding to the son?
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Autonomy
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Which outcome statement is the best indicator that Mr. Johnson's pneumonia is resolves and he is ready to be discharged?
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Sputum culture is negative
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Which additional discharge instruction(s) should the nurse include in the teaching plan to promote optimal health for Mr. Johnson?
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-Avoid crowds and people with infections -Store prescribed inhalers away from extreme heat or colds
