NGN RN (SEPSIS) Sample Case Study of a 78-year-old female client Due to Shortness of Breath Answered Correctly 2023/2024.

NGN RN (SEPSIS) Sample Case Study of a 78-year-old female client Due to Shortness of Breath Answered Correctly 2023/2024. The nurse in the emergency department (ED) is caring for a 78-year-old female client. Select the 4 client findings that require immediate follow-up. Nurses’ Notes 1000: Client was brought to the ED by the client’s adult child due to increased shortness of breath this morning. The adult child reports that the client has been running a fever for the past few days and has started to cough up greenish mucus and to complain of soreness throughout the body. Client was hospitalized for issues with atrial fibrillation 6 days ago. History of hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. On assessment, the client’s breathing appears slightly labored, and coarse crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. The adult child states, “Sometimes it seems like my parent is confused.” Peripheral venous access device (VAD) placed in right forearm. 1. vital signs 2. lung sounds 3. capillary refill 4. client orientation 5. radial pulse characteristics 6. characteristics of the cough NGN RN Sample Case (SEPSIS) Study of a 78-year-old female client Due to Shortness of Breath Answered Correctly 2023/2024. Page 3/64 Screen 2 of 6 The nurse in the emergency department (ED) is caring for a 78-year-old female client. For each client finding below, click to specify if the finding is consistent with the disease process of pneumonia, a urinary tract infection (UTI), or influenza. Each finding may support more than 1 disease process. Client Findings Pneumonia Urinary Tract Infection Influenza fever confusion body soreness cough and sputum shortness of breath Note: Each column must have at least 1 response option selected. Nurses’ Notes 1000: Client was brought to the ED by the client’s adult child due to increased shortness of breath this morning. The adult child reports that the client has been running a fever for the past few days and has started to cough up greenish mucus and to complain of soreness throughout the body. Client was hospitalized for issues with atrial fibrillation 6 days ago. History of hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. On assessment, the client’s breathing appears slightly labored, and coarse crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. The adult child states, “Sometimes it seems like my parent is confused.” Peripheral venous access device (VAD) placed in right forearm. Page 4/64 Screen 3 of 6 The nurse in the emergency department (ED) is caring for a 78-year-old female client. Complete the following sentence by choosing from the list of options. The client is at highest risk for developing Nurses’ Notes 1000: Client was brought to the ED by the client’s adult child due to increased shortness of breath this morning. The adult child reports that the client has been running a fever for the past few days and has started to cough up greenish mucus and to complain of soreness throughout the body. Client was hospitalized for issues with atrial fibrillation 6 days ago. History of hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. On assessment, the client’s breathing appears slightly labored, and coarse crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. The adult child states, “Sometimes it seems like my parent is confused.” Peripheral venous access device (VAD) placed in right forearm. Select… Page 5/64 Screen 3 of 6 The nurse in the emergency department (ED) is caring for a 78-year-old female client. Complete the following sentence by choosing from the list of options. The client is at highest risk for developing Nurses’ Notes 1000: Client was brought to the ED by the client’s adult child due to increased shortness of breath this morning. The adult child reports that the client has been running a fever for the past few days and has started to cough up greenish mucus and to complain of soreness throughout the body. Client was hospitalized for issues with atrial fibrillation 6 days ago. History of hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. On assessment, the client’s breathing appears slightly labored, and coarse crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. The adult child states, “Sometimes it seems like my parent is confused.” Peripheral venous access device (VAD) placed in right forearm. Select… stroke hypoxia dysrhythmias a pulmonary embolism Select… Page 6/64 Screen 4 of 6 The nurse in the emergency department (ED) is caring for a 78-year-old female client. For each potential nursing intervention, click to specify whether the intervention is indicated or not indicated for the care of the client. Nurses’ Notes 1000: 1200: Client was brought to the ED by the client’s adult child due to increased shortness of breath this morning. The adult child reports that the client has been running a fever for the past few days and has started to cough up greenish mucus and to complain of soreness throughout the body. Client was hospitalized for issues with atrial fibrillation 6 days ago. History of hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. On assessment, the client’s breathing appears slightly labored, and coarse crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. The adult child states, “Sometimes it seems like my parent is confused.” Peripheral venous access device (VAD) placed in right forearm. Called to bedside by the adult child who states that the client “isn’t acting right.” On assessment, client is difficult to arouse, pale, and diaphoretic. Vital signs: P 112, RR 32, BP 90/62, pulse oximetry reading 91% on 2 L/min of oxygen via nasal cannula. Client Findings Indicated Not Indicated Prepare the client for defibrillation. Place client in a semi-Fowler’s position. Request an order to increase the oxygen flow rate. Request an order to insert an additional peripheral VAD. Request an order to administer an intravenous fluid bolus. Note: Each row must have 1 response option selected. The nurse has reviewed the Nurses’ Notes from 1200. Page 7/64 Screen 5 of 6 The nurse in the emergency department (ED) is caring for a 78-year-old female client. The nurse has reviewed the Orders from 1215. Click to highlight the orders that the nurse should consider a priority. Nurses’ Notes 1000: 1200: Client was brought to the ED by the client’s adult child due to increased shortness of breath this morning. The adult child reports that the client has been running a fever for the past few days and has started to cough up greenish mucus and to complain of soreness throughout the body. Client was hospitalized for issues with atrial fibrillation 6 days ago. History of hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. On assessment, the client’s breathing appears slightly labored, and coarse crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. The adult child states, “Sometimes it seems like my parent is confused.” Peripheral venous access device (VAD) placed in right forearm. Called to bedside by the adult child who states that the client “isn’t acting right.” On assessment, client is difficult to arose, pale, and diaphoretic. Vital signs: P 112, RR 32, BP 90/62, pulse oximetry reading 91% on 2 L/min of oxygen via nasal cannula. Orders 1215: • insert an indwelling urethral catheter • vancomycin 1 g, IV, every 12 hours • computed tomography (CT) scan of the chest • 0.9% sodium chloride (normal saline) 500 mL, IV, once • laboratory tests: blood culture and sensitivity (C & S), complete blood count (CBC), arterial blood gas (ABG).