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1. Calvin Umbyuma, a 42-year-old male, has been Maslow's Hierarchy of
Needs - High
admitted for shortness of breath and blood-tinged mu-
pleuritic chest pain. He was diagnosed copurulent
with HIV over a year ago. He recently sputum and
traveled Kenya, to visit his mother, reports pain
who is ill. While visiting his moth- er, during coughing
he received herbal therapies to help episodes rated as
with the manifestations he was a 5 on a 0 to 10
experiencing. Vital signs are temperature pain scale. S1S2
100.9°F (38.3° C), respi- rations 22/min, heart tones
heart rate 92/min, blood pres- sure noted, All puls- es
152/89 mmHg, oxygen saturation 91% on palpable. Abdomen
room air. Inflammatory markers including is soft and non-
ery- throcyte sedimentation rate (ESR) and tender. Bowel
c-reac- tive protein (CRP) are elevated at sounds active in
78.9 mmh and all 4 quadrants.
67.2 mg/L. The client has been placed in a Client
neg- ative pressure room at the end of
the hallway.
2. Calvin Umbyuma
The nurse reviews the information
received in the report and enters the
client's room to perform a physical
assessment. Upon assess- ment, the
client is alert and oriented to per- son,
place, time, and event. Pupils are equal,
round, reactive to light, and
accommodation.
Lung sounds reveal crackles in right
upper lobe. Client is expectorating
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riority
BCs - High Priority
afety and Risk Reduction - High Pri- ority
rgent vs Nonurgent - High Priority Chronic vs Acute/Stable vs Unstable -
High Priority
Which of the following concerns should the nurse address while pro-
viding client care? (Select all that ap- ply.)
orrect Options: Physiological: Comfort Health Promotion:
Education Physiological: Immunity Physiological: Infection
ncorrect Options: Physiological: Nutrition Physiological: Mobility
Physiological: Clotting Physiological: Grief
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is lying in semi-Fowler's position. Call
light is within reach.
3. Calvin Umbyuma When planning client care, which
of
The nurse is planning client care and reviewing the following actions
should the nurse
information in the electronic medical take?
record (EMR). During episodes of Correct
coughing, the client expectorates :
sputum that is blood-tinged and Prepare to obtain a sputum
specimen
greenish yellow in color. The client reports that culture
the pain increases during episodes of cough- Place the client on
airborne isolation
ing. When examining the client's previous chest precautions
x-ray, the nurse identifies an area of The client calls the
patchy shadowing in the right upper nurse to report
lobe. The client reports having night severe pain when
sweats and waking up through the coughing and a
night for the past 4 weeks being worsening of
drenched in sweat. The client stated shortness of
that they have traveled to Kenya twice breath. When
this year to care for their ill parent. The entering the
client reports that their parent has not client's room to
received treatment for their illness at a administer a PRN
medical facility but does practice pain medication,
naturopathic medicine. The client the nurse
reports us- ing provider prescribed
medications, darunavir 800 mg with
ritonavir 100 mg, ...etc
4. Calvin Umbyuma
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Review client's immunization record for bacillus Calmette-Guerin
vaccine
Incorrect:
Which of the following actions
Prepare to administer client's herbal therapies
should the nurse take?
Preform venipuncture on client's right hand to obtain blood for
Correct:
culture Listen to the client's lung
sounds Preform a medication
reconciliation
notices the client has a visitor in the room who with the client's
medications and ther-
apies.