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Ati lpn level 3 med surg resp test
Total Questions : 17
Showing 10 questions, Sign in for moreClient presents to emergency department with report of shortness of breath for 2 days, with headache, chills, fever, sore throat, and cough. States went to a music concert recently "and probably picked up some kind of virus."
Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.
Client's face is flushed, sinus tachycardia, rate of 109/min. S1 and S2 heart sounds heard on auscultation. Pulses palpable.
Breath sounds with crackles to right lower lobe, tachypnea. rate of 28/min. Frequent productive cough with thick rusty sputum. Client denies hemoptysis. Unable to lie down, states "more comfortable to sit up."
Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."
Reports decreased urination over past 24 hr. "Haven't been drinking as much water as I should because my throat hurts."
Client reports they have not had a pneumococcal vaccine and do not get annual influenza vaccinations. States "I just hate needles.
1200:
Temperature 38.6° C (101.5° F)
Heart rate 109/min
Respiratory rate 28/min
Blood pressure 106/54 mm Hg
Oxygen saturation 94% on room air
1215:
70 years of age
No significant medical history other than primary concern
Well-nourished
Home Medications
Daily multivitamin
Vitamin D
Social History
Lives alone partner died 5 years ago
Drinks 1 to 2 glasses of red wine daily
Has never smoked
Walks 2 to 3 miles 6 days/week
1230
Chest x-ray: Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia
A nurse in an emergency department is assisting with admitting a client.
A nurse is caring for a client who has pneumonia. Select the 4 findings in the client's medical record that places them at risk for pneumonia.
A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse?
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
A nurse is collecting data on a client who has respiratory alkalosis. Which of the following findings should the nurse expect?
A nurse is reinforcing teaching with a client who has a new prescription for nebulizer treatments. Which of the following client statements indicates to the nurse a need for further teaching?
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?
A nurse is assisting discharge planning for a client who has a new prescription for bi-level positive airway pressure (BIPAP). The nurse should plan to contact which of the following healthcare team members to educate the client?
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