PN COPD w/ Pneumonia (Evolve) – Flashcards
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Which data should the PN collect next?
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Auscultate breath sounds
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The PN recognizes which finding supports Dan's diagnosis of pneumonia?
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Pulse rate of 115
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Dan's ABGs are: pH- 7.28 pCO2- 55 HCO3- 25 pO2- 89 Based on these ABG results the PN recognizes the client is experiencing which acid-base imbalance?
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Respiratory acidosis
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When helping plan care for Dan, which nursing diagnosis has the highest priority?
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Ineffective airway clearance.
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Which is the most important intervention for the PN to implement for Dan's priority nursing diagnosis?
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Monitor rate and depth of respirations.
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Which outcome should the PN expect to note in Dan's plan care for the priority nursing diagnosis?
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Respiration rate will be 16 breaths per minute by the 4th hospital day.
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Methyl-prednisone 125 mg IVBP ordered. Dose on hand is 250 mg/mL.
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0.5 mL
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Before administration of the first dose of Unasyn by the RN, which action should the PN implement?
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Obtain sputum specimen.
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While Dan is receiving Ventolin, which is the most important action for the PN to perform?
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Monitor pulse and BP
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What client instruction should the PN reinforce after observing Dan?
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Wait at least 1 min. Between each puff of the same medication.
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Which lab tests should the PN monitor for the client taking Azmacort? (Select all that apply)
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Potassium Blood Glucose Calcium
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For an acute episode of asthma, what additional instruction should the PN provide for Dan? (Select all that apply)
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Use the Ventolin inhaler for acute asthma attacks. Do not discontinue the drugs, unless directed by the ordering HCP.
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After checking the sensor site to make sure the oxygen saturation readings are accurate, which intervention should the PN initiate next?
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Elevate the head of the bed to a high-fowler's position.
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To ensure accurate oxygen saturation readings via pulse oximeter, which action should the PN implement?
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Determine adequacy of circulation prior to applying sensor.
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To promote effective communication with Dan, how should the PN respond?
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"You seem pretty upset this morning."
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How should the PN respond to Dan?
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Remain silent.
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What action should the PN take?
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Instruct the UAP regarding the correct transfer of a client with a nasal cannula.
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Which one of these rights was violated in the above situation?
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Right direction.
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Which intervention should the PN implement immediately?
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Place resuscitation equipment in the room.
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Before responding to Jack, which ethical principle should the PN consider?
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Autonomy.
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Which outcome statement is the best indicator that Dan's pneumonia is resolved and he is ready to be discharged?
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Sputum culture is negative.
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Which additional discharge instruction should the PN reinforce when talking with Dan to promote optimal health?
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Avoid crowds and people with infections.
