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Hesi rn adult health
Total Questions : 57
Showing 10 questions, Sign in for moreThe client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.
The nurse is preparing to set up the oxygen administration and apply the simple face mask.
0815
Vital signs:
Temperature 97.5° F (36.4° C) Heart rate 104 beats/minute Respirations 29 breaths/minute Blood pressure 119/82 mm Hg Oxygen saturation 89%
Oxygen mask applied.
Orders
0800
Admit to the medical floor Vital signs every 4 hours Continuous pulse oximetry
Supplemental oxygen 10 L/min via nasal cannula Enalapril 10 mg PO every morning
Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5° F (38° C) . Send blood for a complete blood count, electrolytes
Chest x-ray now
0815
Supplemental oxygen 10 L/min via simple face
Patient Data
What order(s) would the nurse question? (Select all that apply.)
The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.
The nurse is preparing to set up the oxygen administration and apply the simple face mask.
0815
Vital signs:
Temperature 97.5° F (36.4° C) Heart rate 104 beats/minute Respirations 29 breaths/minute Blood pressure 119/82 mm Hg Oxygen saturation 89%
Oxygen mask applied.
Orders
0800
Admit to the medical floor Vital signs every 4 hours Continuous pulse oximetry
Supplemental oxygen 10 L/min via nasal cannula Enalapril 10 mg PO every morning
Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5° F (38° C) . Send blood for a complete blood count, electrolytes
Chest x-ray now
0815
Supplemental oxygen 10 L/min via simple face
Patient Data
What should the nurse do before applying the face mask? Select that apply.
The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.
0815
Vital signs:
Temperature 97.5° F (36.4° C) Heart rate 104 beats/minute Respirations 29 breaths/minute Blood pressure 119/82 mm Hg Oxygen saturation 89%
Oxygen mask applied.
0800
- Admit to the medical floor Vital signs every 4 hours Continuous pulse oximetry
- Supplemental oxygen 10 L/min via nasal cannula Enalapril 10 mg PO every morning
- Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5° F (38° C) . Send blood for a complete blood count, electrolytes
- Chest x-ray now
0815
- Supplemental oxygen 10 L/min via simple face
Patient Data
According to the client's vital signs, he is experiencing
Explanation
Tachypnea refers to abnormally rapid breathing, characterized by an increased respiratory rate. In adults, tachypnea is typically defined as a respiratory rate above 20 breaths per minute at rest.
Tachycardia is a medical condition characterized by a rapid heart rate, typically above 100 beats per minute in adults at rest.
Eupnea refers to normal, unlabored breathing at a normal rate and depth. It is characterized by regular inhalations and exhalations without any signs of respiratory distress or abnormalities.
Hypothermia is a medical condition characterized by an abnormally low body temperature, typically below 95°F (35°C).
Bradycardia is a medical condition characterized by an abnormally slow heart rate, typically below 60 beats per minute in adults.
Hyperthermia is a medical condition characterized by an abnormally high body temperature, typically above 100.4°F (38°C).
The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.
The nurse is preparing to set up the oxygen administration and apply the simple face mask.
0815
Vital signs:
Temperature 97.5° F (36.4° C) Heart rate 104 beats/minute Respirations 29 breaths/minute Blood pressure 119/82 mm Hg Oxygen saturation 89%
Oxygen mask applied.
Orders
0800
Admit to the medical floor Vital signs every 4 hours Continuous pulse oximetry
Supplemental oxygen 10 L/min via nasal cannula Enalapril 10 mg PO every morning
Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5° F (38° C) . Send blood for a complete blood count, electrolytes
Chest x-ray now
0815
Supplemental oxygen 10 L/min via simple face
Patient Data
What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.
The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.
The nurse is preparing to set up the oxygen administration and apply the simple face mask.
0815
Vital signs:
Temperature 97.5° F (36.4° C) Heart rate 104 beats/minute Respirations 29 breaths/minute Blood pressure 119/82 mm Hg Oxygen saturation 89%
Oxygen mask applied.
Orders
0800
Admit to the medical floor Vital signs every 4 hours Continuous pulse oximetry
Supplemental oxygen 10 L/min via nasal cannula Enalapril 10 mg PO every morning
Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5° F (38° C) . Send blood for a complete blood count, electrolytes
Chest x-ray now
0815
Supplemental oxygen 10 L/min via simple face
Patient Data
Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings
Explanation
A. Rhonchi are abnormal breath sounds that indicate the presence of mucus or fluid in the airways. Finding rhonchi in the right lung suggests the presence of respiratory congestion or obstruction, which may indicate ineffective treatment or ongoing respiratory issues.
B. Symmetric chest expansion indicates equal and adequate movement of both sides of the chest during inhalation. This finding suggests that there are no restrictions or abnormalities in the chest wall or lung tissue, which is indicative of effective treatment.
C. Oxygen saturation greater than 94% indicates adequate oxygenation of the blood, which is a positive indicator of effective treatment, particularly in clients with respiratory issues such as pneumonia or COPD.
D. A PaCO2 level of 55 mm Hg indicates hypercapnia, which is an elevated level of carbon dioxide in the blood. This finding suggests inadequate ventilation or respiratory failure, indicating ineffective treatment.
E. The ability to ambulate without experiencing shortness of breath suggests improved respiratory function and effective treatment, as it indicates adequate oxygenation and ventilation.
F. Diminished breath sounds suggest reduced airflow or lung volume in the affected area. This finding may indicate ongoing respiratory issues or incomplete resolution of the condition, suggesting ineffective treatment.
The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.
The nurse is preparing to set up the oxygen administration and apply the simple face mask.
0815
Vital signs:
Temperature 97.5° F (36.4° C) Heart rate 104 beats/minute Respirations 29 breaths/minute Blood pressure 119/82 mm Hg Oxygen saturation 89%
Oxygen mask applied.
Orders
0800
Admit to the medical floor Vital signs every 4 hours Continuous pulse oximetry
Supplemental oxygen 10 L/min via nasal cannula Enalapril 10 mg PO every morning
Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5° F (38° C) . Send blood for a complete blood count, electrolytes
Chest x-ray now
0815
Supplemental oxygen 10 L/min via simple face
Patient Data
Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?
A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?
The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
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