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HESI RN Fundamentals
Total Questions : 57
Showing 10 questions, Sign in for moreThe emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.
13:30
Upon initial focused assessment, the child reveals subcostal retractions, nasal drainage, skin is hot to the touch, and has a dry cough. Breath sounds reveal diffuse wheezing. Nasal swabs collected and sent to the laboratory. Client’s weight is 12 pounds (5.4 kg).
14:00
Administered acetaminophen PO. Respiratory therapy called for oxygen therapy. 14:45
Respiratory rate and oxygen saturation improved. Temperature is within normal limits. The laboratory called with respiratory panel results. The client is positive for respiratory syncytial virus (RSV).
|
Laboratory |
Results |
Reference Ranges |
|
Nasal culture |
Positive for respiratory syncytial virus |
Negative |
- Temperature: 103°F (39.4°C) recently
- Heart rate: 200 beats/minute
- Respirations: 70 breaths/minute
- Oxygen saturation: 90% on room air
- Administer 2.5 mL acetaminophen PO every 4 to 6 hours for temperature over 100.4°F (38°C).
- Obtain nasal swab for respiratory nasal culture.
Chart Reviewed
For each statement, click to indicate whether the statement is true or false.
Explanation
Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.
Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.
Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.
Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.
Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.
2/15/2021
The patient is a 36-year-old female who is in the clinic today for insomnia. She reports that she started having trouble sleeping over a year ago after her father’s death. She has no medical problems and has never had surgery. She takes an oral contraceptive and a multivitamin daily. She does not smoke but drinks one to two glasses of wine every evening.
2/15/2021
Vital Signs:
- Temperature: 97°F (36.1°C) orally
- Heart rate: 59 beats/minute
- Respiratory rate: 16 breaths/minute
- Blood pressure: 116/72 mm Hg
Educated the patient on sleep hygiene techniques, such as avoiding exercise and caffeine right before bed.
3/2/2021
The patient is in the clinic following up after her sleep study, which showed no signs of sleep apnea. The patient continues to have poor sleep even with eliminating caffeine and doing a relaxing activity before bed, such as yoga. The patient will keep a sleep journal to document her sleep for the next 2 weeks.
3/16/2021
The patient completed a 2-week sleep journal. The patient falls asleep 1 to 2 hours after going to bed and wakes up 2 to 3 times per night. She does not have to use the restroom during the night. She experiences daytime drowsiness and headaches nowadays.
2/15/2021
Sleep study for 1 night.
What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.
The client is a 56-year-old woman who had an anteroposterior spinal fusion 2 days ago. She tolerated the procedure well and has been progressively increasing her walking distance.
12:00
Vital Signs:
- Heart rate: 98 beats/minute
- Pain rating: 5 on a 0 to 10 pain scale
Morphine 2.5 mg given IV push (IVP). The client ambulated twice with physical therapy.
13:00
Vital Signs:
- Heart rate: 78 beats/minute
- Pain rating: 3 on a 0 to 10 pain scale
Ibuprofen 800 mg given PO. The client is resting in bed.
14:00
Vital Signs:
- Heart rate: 118 beats/minute
- Pain rating: 8 on a 0 to 10 pain scale
- Up ad lib
- Regular diet
- Ibuprofen 800 mg PO every 8 hours for pain rated at 2 to 4 on a 0 to 10 pain scale
- Morphine 2.5 mg IV push every 4 hours for pain greater than 4 on a 0 to 10 pain scale
Patient Data
Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
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