breathing patterns HESI
In assessing James' breath sounds, the nurse should ask him to perform which action?
Breathe deeply through the mouth.
When assessing James' breath sounds, where should the nurse listen first?
Lung apices.
How should the nurse respond?
"A large first dose allows the medication to start working faster."
To encourage the mother to share more about her feelings, how should the nurse respond?
"It sounds like this has been a very frightening experience for you."
Which response is best for the nurse to provide?
"The clip feels like squeezing your finger with your other hand."
James' mother further states that she is worried her 2-year-old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother's concern about her daughter?
"There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms."
The antitussive medication label reads, "Take 2 teaspoonfuls every 4 hours as needed." The nurse gives James some mL medication cups and teaches James and his mother how to pour the medication into the mL cup. To what mL level should the medication be poured? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
10
When applying a nasal cannula in the ED, what action is most important for the nurse to implement to ensure client safety?
Determine that all electrical equipment in the room is functioning correctly and is properly grounded.
The HCP prescribes a complete blood count (CBC) as a part of the diagnostic workup on James. Which is the best explanation for the HCP's prescriptions?
A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults.
Which outcome statement should the nurse use for James' plan of care?
James' oxygen saturation will be greater than 95% on room air.
Which is the most important approach for the nurse to use when applying a nasal cannula?
Check that the openings in the nasal prongs are aimed into the nose to prevent skin breakdown.
To measure capillary refill, the nurse must first perform which action?
Compress the nailbed of one finger until it blanches.
Upon further observation, the nurse describes James' sputum as "tenacious." To what does "tenacious" refer?
Consistency
What action should the nurse implement prior to applying the sensor?
Determine if James has a latex allergy.
After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care?
Establish goals and expected outcomes.
Which documentation best reflects the nurse's objective assessment?
Frequent deep cough, producing small amounts of pale yellow sputum.
Which nursing diagnosis is most relevant to James' current status?
Impaired gas exchange.
When assisting James obtain a sputum specimen, what action should the nurse take?
Instruct James to cough deeply from the chest and spit into the specimen cup.
Which documentation reflects subjective data?
James reports that he is coughing a lot.
Because of James' dyspnea, the nurse is concerned that he may need to receive oxygen. To determine the need for supplemental oxygen, which assessment is most important for the nurse to perform?
Measure oxygen saturation.
Assessment SkillsThe nurse assesses James' vital signs. His respirations are rapid and shallow. Which is the best technique for the nurse to use to assess James' respirations accurately?
Place a hand on James' upper abdomen and observe the rise and fall of the chest.
What immediate actions should the nurse implement?
Reposition the finger clip and obtain another reading. Assess James for signs and symptoms of respiratory distress. Encourage James to begin coughing and deep breathing.
The nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should the nurse take?
Record the presence of clear breath sounds.
The liquid cough syrup is labeled as an antitussive. The nurse explains that this medication should have what effect?
Reduce the frequency of the cough.
Which assessment finding further supports diagnosis?
Restlessness and fatigue.
Which action by the nurse demonstrates the use of trust in the nurse-client relationship?
Returning to the room at the time promised.
James' respiratory rate is 36 breaths/min. How should the nurse describe James' respiratory pattern?
Tachypnea
The client-care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide?
Wear clean gloves to place the specimen cup in a biohazard bag for transport.
James' mother states that this is the third time in recent months she has brought him to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections James has had within the past year. Why does the nurse ask this?
To assess for a possible immune deficiency disorder.
Which serum lab value confirms the resolution of James' infection?
White blood cell count (WBC) 6,000/mm3.
