PN COPD w/ Pneumonia (Evolve)

Which data should the PN collect next?
Auscultate breath sounds
The PN recognizes which finding supports Dan’s diagnosis of pneumonia?
Pulse rate of 115
Dan’s ABGs are:
pH- 7.28
pCO2- 55
HCO3- 25
pO2- 89
Based on these ABG results the PN recognizes the client is experiencing which acid-base imbalance?
Respiratory acidosis
When helping plan care for Dan, which nursing diagnosis has the highest priority?
Ineffective airway clearance.
Which is the most important intervention for the PN to implement for Dan’s priority nursing diagnosis?
Monitor rate and depth of respirations.

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Which outcome should the PN expect to note in Dan’s plan care for the priority nursing diagnosis?
Respiration rate will be 16 breaths per minute by the 4th hospital day.
Methyl-prednisone 125 mg IVBP ordered.
Dose on hand is 250 mg/mL.
0.5 mL
Before administration of the first dose of Unasyn by the RN, which action should the PN implement?
Obtain sputum specimen.
While Dan is receiving Ventolin, which is the most important action for the PN to perform?
Monitor pulse and BP
What client instruction should the PN reinforce after observing Dan?
Wait at least 1 min. Between each puff of the same medication.
Which lab tests should the PN monitor for the client taking Azmacort? (Select all that apply)
Potassium
Blood Glucose
Calcium
For an acute episode of asthma, what additional instruction should the PN provide for Dan? (Select all that apply)
Use the Ventolin inhaler for acute asthma attacks.

Do not discontinue the drugs, unless directed by the ordering HCP.

After checking the sensor site to make sure the oxygen saturation readings are accurate, which intervention should the PN initiate next?
Elevate the head of the bed to a high-fowler’s position.
To ensure accurate oxygen saturation readings via pulse oximeter, which action should the PN implement?
Determine adequacy of circulation prior to applying sensor.
To promote effective communication with Dan, how should the PN respond?
“You seem pretty upset this morning.”
How should the PN respond to Dan?
Remain silent.
What action should the PN take?
Instruct the UAP regarding the correct transfer of a client with a nasal cannula.
Which one of these rights was violated in the above situation?
Right direction.
Which intervention should the PN implement immediately?
Place resuscitation equipment in the room.
Before responding to Jack, which ethical principle should the PN consider?
Autonomy.
Which outcome statement is the best indicator that Dan’s pneumonia is resolved and he is ready to be discharged?
Sputum culture is negative.
Which additional discharge instruction should the PN reinforce when talking with Dan to promote optimal health?
Avoid crowds and people with infections.
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