a client with pneumonia is receiving oxygen therapy what assessment finding requires immediate intervention
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Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?

Correct answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.

2. A client with diabetes mellitus is admitted with an infected foot ulcer. What intervention is most important for the nurse to implement?

Correct answer: B

Rationale: Administering prescribed IV antibiotics is the most crucial intervention in managing an infected foot ulcer in a client with diabetes mellitus. Antibiotics help combat the infection and prevent its spread systemically, which is vital in diabetic clients to prevent serious complications like sepsis. While obtaining a wound culture (Choice A) may provide valuable information for targeted antibiotic therapy, administering antibiotics promptly takes precedence to prevent the infection from worsening. Elevating the affected foot (Choice C) can help reduce swelling but is not as urgent as administering antibiotics. Consulting the wound care nurse (Choice D) may be beneficial for long-term wound management but does not address the immediate need to control the infection.

3. The nurse is reviewing the laboratory results of a client with chronic kidney disease. The client's serum calcium level is 7.5 mg/dL. Which condition should the nurse suspect?

Correct answer: D

Rationale: A serum calcium level of 7.5 mg/dL is indicative of hypocalcemia, a common complication in clients with chronic kidney disease due to impaired calcium absorption and metabolism. Hypercalcemia (Choice A) is the opposite of the condition presented in the question and is characterized by elevated serum calcium levels. Hyperkalemia (Choice B) is an increased potassium level, not related to the client's serum calcium level. Hyponatremia (Choice C) is a decreased sodium level and is also not related to the client's serum calcium level.

4. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?

Correct answer: D

Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.

5. A client is prescribed an inhaled corticosteroid for asthma management. Which instruction should the nurse provide to the client regarding the use of this medication?

Correct answer: A

Rationale: The correct instruction for a client using an inhaled corticosteroid for asthma management is to rinse the mouth after using the inhaler. This helps prevent oral thrush, a common side effect of corticosteroid inhalers. Holding the breath for 5 seconds after inhaling the medication (Choice B) is not necessary for corticosteroid inhalers. Using the inhaler during an acute asthma attack (Choice C) is not the purpose of corticosteroids, which are used for long-term asthma management. Taking the medication only when symptoms occur (Choice D) is not correct as corticosteroids are typically used regularly to control asthma symptoms.

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