a client with a history of chronic obstructive pulmonary disease copd is admitted to the hospital the client is experiencing difficulty breathing and
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Nursing Elites

HESI LPN

HESI CAT Exam Quizlet

1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. The client is experiencing difficulty breathing and is very anxious. The nurse notes that the client’s oxygen saturation is 88% on room air. Which action should the nurse implement first?

Correct answer: B

Rationale: Administering supplemental oxygen is the first priority to address low oxygen saturation and ease breathing. In a client with COPD experiencing difficulty breathing and anxiety with oxygen saturation at 88%, providing supplemental oxygen takes precedence over other actions. Placing the client in a high Fowler’s position may help with breathing but does not address the immediate need for increased oxygenation. Performing a thorough respiratory assessment is important but should come after stabilizing the client's oxygen levels. Starting an IV infusion of normal saline is not the priority in this situation and does not directly address the client's respiratory distress.

2. Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?

Correct answer: B

Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.

3. The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Correct answer: C

Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.

4. A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which action has the highest priority?

Correct answer: C

Rationale: Assigning a private room has the highest priority in this scenario. It helps prevent the spread of H1N1 influenza to other patients and protects both the patient and others from potential infection. Obtaining specimens for cultures and monitoring vital signs are important but do not address the immediate need to prevent the spread of the virus. Administering Ringer's Lactate IV is not the priority in this case as it does not directly address the infectious nature of the condition.

5. What nursing intervention is most important to implement after a client has completed a myelogram?

Correct answer: C

Rationale: The correct answer is C: Neurovascular assessment of the lower extremities. After a myelogram, it is crucial to monitor the neurovascular status to detect any signs of complications such as impaired circulation or nerve damage. This assessment helps in identifying early signs of vascular compromise or neurological deficits. Choices A, B, and D are not the priority after a myelogram. Lie-sit-stand blood pressure measurement is not directly related to post-myelogram care. Abdominal assessment and skin assessment are important but not the priority immediately after this procedure.

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