The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intensive care unit. The client lives with his daughter and her family, who report that he is compliant with his medication regimen. The client walks every morning but has shown cognitive decline at home and has no signs of improvement. The client has been experiencing increased confusion, lethargy, and decreased appetite. He has also developed a persistent cough with greenish sputum and shortness of breath.

Hypertension
Heart failure
Seasonal allergies
Pneumonia (admitted 3 days ago)

White Blood Cell (WBC) count: 15,000/mm³ (4,500-11,000/mm³)
C-reactive protein (CRP): 12 mg/L (<3 mg/L)
Blood urea nitrogen (BUN): 25 mg/dL (7-20 mg/dL)
Serum creatinine: 1.5 mg/dL (0.6-1.2 mg/dL)
Chest X-ray: Bilateral infiltrates

Temperature: 38.5°C (101.3°F)
Heart rate: 110 beats per minute
Respiratory rate: 28 breaths per minute
Blood pressure: 140/90 mmHg
Oxygen saturation: 88% on room air

Administer IV antibiotics as prescribed
Administer oxygen therapy to maintain SpO2 > 92%
Monitor vital signs every 4 hours
Encourage fluid intake
Perform chest physiotherapy

The client appears pale and diaphoretic. He has bilateral crackles in the lower lung fields and diminished breath sounds. The client is using accessory muscles to breathe and has a productive cough with greenish sputum. His skin is warm to the touch, and he has mild peripheral edema in the lower extremities. The client is alert but disoriented to time and place.

HESI RN Fundamentals Exam 1 ( 55 Questions)

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