NGN RN Sample Case (SEPSIS) Study of a 78-year-old female client Due
to Shortness of Breath Answered Correctly 2023/2024.
Screen 1 of 6
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 1. vital signs
1000: Client was brought to the ED by the client’s adult child due to increased 2. lung sounds
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 3. capillary refill
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of 4. client orientation
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 5. radial pulse characteristics
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 6. characteristics of the cough
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 2/64
, 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.
Nurses’ Notes
Urinary Tract
1000: Client was brought to the ED by the client’s adult child due to increased Client Findings Pneumonia Influenza
Infection
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 fever
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of confusion
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. body soreness
On assessment, the client’s breathing appears slightly labored, and coarse
cough and sputum
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 shortness of breath
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. Note: Each column must have at least 1 response option selected.
Page 3/64
, 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 Select…
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 Select…
Nurses’ Notes
Select…
1000: Client was brought to the ED by the client’s adult child due to increased stroke
shortness of breath this morning. The adult child reports that the client has hypoxia
been running a fever for the past few days and has started to cough up
dysrhythmias
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of a pulmonary embolism
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 5/64
to Shortness of Breath Answered Correctly 2023/2024.
Screen 1 of 6
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 1. vital signs
1000: Client was brought to the ED by the client’s adult child due to increased 2. lung sounds
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 3. capillary refill
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of 4. client orientation
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 5. radial pulse characteristics
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 6. characteristics of the cough
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 2/64
, 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.
Nurses’ Notes
Urinary Tract
1000: Client was brought to the ED by the client’s adult child due to increased Client Findings Pneumonia Influenza
Infection
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 fever
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of confusion
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. body soreness
On assessment, the client’s breathing appears slightly labored, and coarse
cough and sputum
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 shortness of breath
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. Note: Each column must have at least 1 response option selected.
Page 3/64
, 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 Select…
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 Select…
Nurses’ Notes
Select…
1000: Client was brought to the ED by the client’s adult child due to increased stroke
shortness of breath this morning. The adult child reports that the client has hypoxia
been running a fever for the past few days and has started to cough up
dysrhythmias
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of a pulmonary embolism
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 5/64
