a client with chronic obstructive pulmonary disease copd is admitted with pneumonia which assessment finding requires immediate intervention
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam

1. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and can signal respiratory failure in a client with COPD. This finding requires immediate intervention to prevent further respiratory compromise. Oxygen saturation of 90% indicates some oxygenation impairment but may not necessitate immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but does not indicate immediate respiratory distress. Inspiratory crackles may be present in pneumonia but do not require immediate intervention compared to the increased work of breathing indicated by the use of accessory muscles.

2. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother. During the assessment, the mother asks the nurse why her child is at the 5th percentile for growth. What response is best for the nurse to provide?

Correct answer: B

Rationale: Heart disease can affect growth, leading to smaller size in children.

3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?

Correct answer: C

Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.

4. After checking the fingerstick glucose at 1630, what action should be implemented?

Correct answer: B

Rationale: Administering insulin aspart (rapid-acting insulin) is the appropriate action to manage the elevated glucose level of 1630. Choice A, notifying the healthcare provider, is not the immediate action needed for this glucose level. Choice C, giving an IV bolus of Dextrose 50%, would exacerbate hyperglycemia instead of treating it. Choice D, performing quality control on the glucometer, is not relevant to the management of the patient's glucose level at this time.

5. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Correct answer: A

Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.

Similar Questions

The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding requires immediate intervention?
The nurse is caring for a client with a history of atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beats/minute. What action should the charge nurse implement?
After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?
The healthcare provider is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding is most concerning?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses