HESI Case Study: COPD with Pneumonia Test Questions
and Answers Graded A+
The physical examination reveals the following:
Vital signs: temperature 101.6° F (38.6° C), heart
rate 110 beats/minute, respirations 32 7. The levofloxacin 500 mg IVPB is supplied in
breaths/minute, blood pressure 132/78 mmHg. 100 mL of 5% dextrose to be delivered over 60
Respirations shallow and labored, with use of minutes. There is no IV pump available, so the
respiratory accessory muscles. nurse will infuse the antibiotic by gravity. The
Increased anteroposterior (AP) diameter of the drop factor on the tubing is 20 gtts/mL. The nurse
chest. should set the IVPB to infuse at how many gtts
Skin dry and warm to touch, with inelastic skin per min? (Enter numerical value only. If rounding
turgor, and fingernail clubbing present. is necessary, round to the whole number.) -
1.Which assessment is most important for the ANSWER -33
nurse to complete next? - ANSWER -
Auscultate breath sounds.
8. While the client is undergoing nebulizer
treatments with albuterol, which assessment is it
2. With a diagnosis of pneumonia, which most important for the nurse to perform? -
assessment finding warrants immediate ANSWER -Monitor pulse and blood
intervention by the nurse? - ANSWER - pressure.
Oxygen saturation 90%.
The nurse observes the client using the MDI.
pH 7.25 7.35 to 7.45 7.35 to 7.45 Using a spacer, the client takes 2 puffs of
pCO2 58 35 to 45 mmHg 35 to 45 mmHg albuterol, followed one minute later by 2 puffs of
HCO3 26 21 to 28 mEq/L 21 to 28 mmol/L beclomethasone.
pO2 87 80 to 100 mmHg 80 to 100 mmHg 9. After observing the client, which instruction by
3. The ABG results indicate that the client is the nurse is most important for client teaching?
experiencing which acid-base imbalance? - (Select all that apply.) - ANSWER -Tell the
ANSWER -Respiratory acidosis. client to wait at least 5 minutes between each
medication.
4. Which nursing problem has the highest priority
when the nurse is planning care for the client? - 10. Which instruction should the nurse provide
ANSWER -Ineffective airway clearance. the client for an acute episode of asthma? -
ANSWER -Use the albuterol inhaler for an
acute asthma attack.
5. Which assessment finding warrants immediate
intervention by the nurse? - ANSWER -
Kussmal respirations. Continuous monitoring of the client's oxygen
saturation indicates readings ranging between
92% and 93%. Normal oxygen saturation for a
6. Which nursing action should be implemented healthy adult ranges between 98% and 100%.
before the prescribed levofloxacin is 11. After checking the sensor site to make sure
administered? - ANSWER -Obtain a the readings are accurate, the nurse should then
sputum culture with sensitivity. initiate which intervention? - ANSWER -
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and Answers Graded A+
The physical examination reveals the following:
Vital signs: temperature 101.6° F (38.6° C), heart
rate 110 beats/minute, respirations 32 7. The levofloxacin 500 mg IVPB is supplied in
breaths/minute, blood pressure 132/78 mmHg. 100 mL of 5% dextrose to be delivered over 60
Respirations shallow and labored, with use of minutes. There is no IV pump available, so the
respiratory accessory muscles. nurse will infuse the antibiotic by gravity. The
Increased anteroposterior (AP) diameter of the drop factor on the tubing is 20 gtts/mL. The nurse
chest. should set the IVPB to infuse at how many gtts
Skin dry and warm to touch, with inelastic skin per min? (Enter numerical value only. If rounding
turgor, and fingernail clubbing present. is necessary, round to the whole number.) -
1.Which assessment is most important for the ANSWER -33
nurse to complete next? - ANSWER -
Auscultate breath sounds.
8. While the client is undergoing nebulizer
treatments with albuterol, which assessment is it
2. With a diagnosis of pneumonia, which most important for the nurse to perform? -
assessment finding warrants immediate ANSWER -Monitor pulse and blood
intervention by the nurse? - ANSWER - pressure.
Oxygen saturation 90%.
The nurse observes the client using the MDI.
pH 7.25 7.35 to 7.45 7.35 to 7.45 Using a spacer, the client takes 2 puffs of
pCO2 58 35 to 45 mmHg 35 to 45 mmHg albuterol, followed one minute later by 2 puffs of
HCO3 26 21 to 28 mEq/L 21 to 28 mmol/L beclomethasone.
pO2 87 80 to 100 mmHg 80 to 100 mmHg 9. After observing the client, which instruction by
3. The ABG results indicate that the client is the nurse is most important for client teaching?
experiencing which acid-base imbalance? - (Select all that apply.) - ANSWER -Tell the
ANSWER -Respiratory acidosis. client to wait at least 5 minutes between each
medication.
4. Which nursing problem has the highest priority
when the nurse is planning care for the client? - 10. Which instruction should the nurse provide
ANSWER -Ineffective airway clearance. the client for an acute episode of asthma? -
ANSWER -Use the albuterol inhaler for an
acute asthma attack.
5. Which assessment finding warrants immediate
intervention by the nurse? - ANSWER -
Kussmal respirations. Continuous monitoring of the client's oxygen
saturation indicates readings ranging between
92% and 93%. Normal oxygen saturation for a
6. Which nursing action should be implemented healthy adult ranges between 98% and 100%.
before the prescribed levofloxacin is 11. After checking the sensor site to make sure
administered? - ANSWER -Obtain a the readings are accurate, the nurse should then
sputum culture with sensitivity. initiate which intervention? - ANSWER -
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