NGN HESI RN 2024 EXIT EXAM
QUESTIONS WITH COMPLETE
ANSWERS
When sspreparing ssto ssadminister ssa ssprescribed ssmedication ssto ssa sshomeless ssclient
ssat ssa sscommunity sspsychiatric ssclinic. ssThe ssclient sstells ssthe ssnurse ssthat ssthe
ssusual ssdosage sstaken ssis ssdifferent ssfrom ssthe ssdose ssthe ssnurse ssis ssgiving.
ssWhich ssaction ssshould ssthe ssnurse sstake? ss
A) ssInform ssthe ssclient ssthat sshe ssmay ssrefuse ssthe ssmedication ssand ssdocument
sswhether ssor ssnot ssthe ssclient sstakes ssit. ss
B) ssWithhold ssthe ssmedication ssuntil ssthe ssdosage sscan ssbe ssconfirmed. ss
C) ssExplain ssto ssthe ssclient ssthat ssthe ssdosage sshas ssbeen sschanged. ss
D) ssTell ssthe ssclient ssto sstake ssthe ssmedication ssthen ssverify ssthe ssdosage ssat ssthe
ssnext sshealthcare ssteam ssmeeting. ss- ssANS-B) ssWithhold ssthe ssmedication ssuntil ssthe
ssdosage sscan ssbe ssconfirmed.
The sscharge ssnurse ssis ssmaking ssassignments ssfor ssone sspractical ssnurse ssand
ssthree ssregistered ssnurses sswho ssare sscaring ssfor ssneurologically sscompromised
ssclients. ssWhich ssclient sswith sswhich sschange ssin ssstatus ssis ssbest ssto ssassign ssto
ssthe ssPN? ss
A) ssSubdural sshematoma sswhose ssblood sspressure sschanged ssfrom ss150/80 ssto
ss170/60.
B) ssViral ssmeningitis sswhose sstemperature sschange ssfrom ss101 ssS ssto ss102F. ss
C) ssDiabetic ssketo ssacidosis sswho ssis ssGlasgow sscoma ssscale ssscore sschanged
ssfrom ss10 ssto ss7. ss
D) ssMyxedema, sswhose ssblood sspressure sschange ssfrom ss80/50 ssto ss70/40. ss- ssANS-
B) ssViral ssmeningitis sswhose sstemperature sschange ssfrom ss101 ssS ssto ss102F.
The ssnurse ssis sscaring ssfor ssa ssclient sswith sspneumonia sswho ssnow ssdevelops ssinitial
sssigns ssof ssseptic ssshock ssand ssmulti ssorgan ssfailure. ssThe sshealthcare ssprovider
ssprescribes ssa sssepsis ssprotocol. ssWhich ssintervention ssis ssmost ssimportant ssfor ssthe
ssnurse ssto ssinclude ssin ssthe ssplan ssof sscare? ss
A) ssMaintain ssstrict ssintake ssand ssoutput. ss
,B) ssKeep sshead ssof ssbed ssraised ss45°. ss
C) ssExcess sswarmth ssof ssextremities. ss
D) ssMonitor ssblood ssglucose sslevel. ss- ssANS-A) ssMaintain ssstrict ssintake ssand
ssoutput.
And ssadolescent ssclient ssis ssadmitted ssto ssthe sshospital ssbecause ssof sswriting ssa
sssuicide ssnote ssto ssa ssteacher ssat ssschool. ssOn ssthe sssecond ssday ssof
sshospitalization, ssthe ssnurse ssasked ssthe ssclient ssto ssmeet sswith ssthe sstreatment
ssteam. ssAfter ssthe ssteam ssmeeting, ssthe ssclient ssleaves ssin sstears ssand ssgoes ssto
sstheir ssroom. ssWhich ssnursing ssintervention ssis ssbest? ss
A) ssLet ssthe ssclient ssrest ssquietly ssin sstheir ssroom ssfor ssa sswhile. ss
B) ssExplore ssthe ssclients ssgoals ssand ssdesire ssfor sstreatment. ss
C) ssAsk ssthe sstreatment ssteam ssabout ssthe ssclients ssbehavior. ss
D) ssGo ssto ssthe ssclients ssroom ssand ssask sswhat sshappened. ss- ssANS-D) ssGo ssto
ssthe ssclients ssroom ssand ssask sswhat sshappened.
The sshealthcare ssprovider ssprescribes ssdalteparin ss200 ssunits ssper sskilogram
sssubcutaneous ssonce ssa ssday ssfor ssa ssclient sswho ssweighs ss154 sspounds. ssThe
ssmedication ssis ssavailable ssand ss25,000 ssunits ssper ssmilliliter ssvial. ssHow ssmany
ssmilliliters ssshould ssthe ssnurse ssadminister? ss(Enter ssnumerical ssvalue ssonly. ssIf
ssrounding ssis ssrequired, ssround ssto ssthe ssnearest ss10th.) ss- ssANS-0.6
NGN: ssThe ssclient ssis ssa ss49-year-old ssmale sswho ssreports ssflu sslike sssymptoms
ssincluding ssfever ssand sschest sscongestion ssfor ssfour ssdays. ssHe sscame ssto ssthe
ssemergency ssdepartment sslast ssnight sswhen sshe sswas sshaving ssmore ssdifficulty
ssbreathing sshe sshas ssa sshistory ssof ss1/2 sspack ssa ssday sscigarette sssmoking ssfor ss20
ssyears. ssHe sshas ssno sssignificant ssmedical ssor sssurgical sshistory. ss
Which sstwo ssorders ssshould ssthe ssnurse sscomplete ssfirst? ss
A) ssSputum ssculture. ss
B) ssStart ssoxygen ss3 ssL ssper ssminute ssvia ssnasal sscannula. ss
C) ssPlace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor. ss
D) ssChest ssx-ray. ss
E) ssAcetominophen ss350 ssmg ssPO ssevery sssix sshours ssfor sstemperature sscontrol. ss
F) ssRun ss0.9% sssodium sschloride ssIV ssinfusion ssat ss150 ssmL ssper sshour. ss
G) ssStart ssperipheral ssIV. ss
H) ssNPO. ss- ssANS-B) ssStart ssoxygen ss3 ssL ssper ssminute ssvia ssnasal sscannula. ss
C) ssPlace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor.
NGN: ss0330: ssplace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor, ssNPO, sssputum
ssculture, ssstart ssa ssperipheral ssIV ssinfusion, ssstart ssoxygen ss3 ssL ssper ssminute ssvia
ssnasal sscannula, ssbegin ss0.9% sssodium sschloride ssIV ssinfusion ssat ss150 ssmL ssper
sshour, ssacetaminophen ss350 ssmg ssPO ssevery sssix sshours ssfor sstemperature.
To ssstart ssthe ssclient sson ssoxygen ssas ssordered sswhich ssitems ssshould ssthe ssnurse
sscollects ssfrom ssthe sssupply ssroom? ssSATA ss
,A) sshumidifier ssbottle. ss
B)Suction sscanister. ss
C)Sterile sswater. ss
D) ssNasal sscannula. ss
E) ssFlow ssmeter. ss
F) ssLambs sswool. ss
G) ssTape. ss- ssANS-D) ssNasal sscannula. ss
E) ssFlow ssmeter.
NGN: ssstates, ssI ssam ssfeeling ssextremely ssanxious ssright ssnow. ssThe ssclient sshas
ssdecreased ssbreath sssounds ssin ssthe ssleft sslower sslow. ssHis ssmucus ssmembranes
ssare ssdry. ssHe sshas ssa ssproductive sscough sswith ssthick, ssyellow sssecretions. ssHis
sscapillary ssrefill ssis ssfour ssseconds. ssVital sssigns, sstemperature ss100.2. ssHeart ssrate
ss101 ssbpm, ssrespiratory ssrate ss28 ssbreaths ssper ssminute, ssblood sspressure ss145/89,
ssoxygen sssaturation ss90% sson ssroom ssair.
(for sseach ssbody sssystem ssclick ssto ssspecify ssthe ssassessment ssfindings ssthat
ssindicates sshypoxia)
Cardiovascular: ssheart ssrate ss100 ssbpm, sscapillary ssrefill ssfor ssseconds, ssblood
sspressure ss145/89.
Neurological: ssanxious, ssawake ssand ssalert, ssrestless.
Respiratory: ssoxygen sssaturation ss90% sson ssroom ssair, ssrespiratory ssrate ss28 ssbpm,
ssproductive sscough. ss- ssANS-Cardiovascular: sscapillary ssrefill ssfor ssseconds, ssblood
sspressure ss145/89.
Neurological: ssanxious, ssrestless.
Respiratory: ssoxygen sssaturation ss90% sson ssroom ssair, ssrespiratory ssrate ss28 ssbpm.
NGN: ssThe ssclient ssis ssa ss49-year-old ssmale sswho ssreports ssflu sslike sssymptoms
ssincluding ssfever ssand sschest sscongestion ssfor ssfour ssdays. ssHe sscame ssto ssthe
ssemergency ssdepartment sslast ssnight sswhen sshe sswas sshaving ssmore ssdifficulty
ssbreathing sshe sshas ssa sshistory ssof ss1/2 sspack ssa ssday sscigarette sssmoking ssfor ss20
ssyears. ssHe sshas ssno sssignificant ssmedical ssor sssurgical sshistory. ss
The ssnurse ssshould ssplace ssthe ssclient ssin ssa ss_______________ ssposition ssto
sspromote ss_____________. ss- ssANS-Semi-Fowler ss, sslung ssexpansion.
NGN: ssOrders: ss0330: ssplace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor,
ssNPO, sssputum ssculture, ssstart ssa ssPIV, ssstart ssoxygen ss3L ssvia ssnasal sscannula,
ssnormal sssaline ss150 ssML ssper sshour, ssacetaminophen ss350mg ssPO ssevery sssix
sshours ssfor sstemp ssgreater ssthan ss101F, sschest ssx-ray.
0500: ssOxygen ss8Lvia sssimple ssfacemask, sstitrate ssto sskeep ssoxygen sssaturation
ssgreater ssthan ss94%.
, (mark sswhether ssthe ssstatements ssby ssthe ssnew ssgrad ssnurse ssindicate
ssunderstanding ssor ssno ssunderstanding ssof ssthe ssuse ssof ssfacemask ssin ssthe sscare
ssof ssthis ssclient)
-I ssshould ssclean ssthe ssfacemask ssonce ssper ssshift.
-The ssclient ssshould sstake ssa ss1 ssto ss2 ssminute ssbreak ssfrom ssthe ssfacemask sseach
sshour.
-I ssshould ssput ssgauze ssunder ssthe sselastic ssstraps ssover ssthe ssears.
-I sscan ssadjust ssthe ssoxygen sslevel sson ssthe ssflow ssmeter ssto sskeep ssthe ssclients
ssoxygen sssaturation ssgreater ssthan ss94%.
-The ssmask ssshould sscover ssonly ssthe ssmouth ssand ssleave ssthe ssnose ssopen ssfor
ssexpiration.
-I ssshould ssplace ssthe ssmask ssfirst ssover ssthe ssnose ssand ssthen sscover ssthe ssmouth.
ss- ssANS--I ssshould ssclean ssthe ssfacemask ssonce ssper ssshift. ss(UNDERSTANDING)
-The ssclient ssshould sstake ssa ss1 ssto ss2 ssminute ssbreak ssfrom ssthe ssfacemask sseach
sshour. ss(NOT ssUNDERSTANDING)
-I ssshould ssput ssgauze ssunder ssthe sselastic ssstraps ssover ssthe ssears. ss(NOT
ssUNDERSTANDING ss????)
-I sscan ssadjust ssthe ssoxygen sslevel sson ssthe ssflow ssmeter ssto sskeep ssthe ssclients
ssoxygen sssaturation ssgreater ssthan ss94%. ss(UNDERSTANDING)
-The ssmask ssshould sscover ssonly ssthe ssmouth ssand ssleave ssthe ssnose ssopen ssfor
ssexpiration. ss(NOT ssUNDERSTANDING)
-I ssshould ssplace ssthe ssmask ssfirst ssover ssthe ssnose ssand ssthen sscover ssthe ssmouth.
ss(UNDERSTANDING)
NGN: ssNurses ssNotes: ss0400, ssthe ssclient ssis ssawake ssand ssalert ssbut ssrestless. ssHe
ssstates ssI ssam ssfeeling ssextremely ssanxious ssright ssnow. ssThe ssclient sshas
ssdecreased ssbreath sssounds ssin ssthe ssleft sslower sslobe. ssHis ssmucus ssmembranes
ssare ssdry. ssHe sshas ssa ssproductive sscough sswith ssthick, ssyellow sssecretions. ssHis
sscapillary ssrefill ssis ssfour ssseconds. ssHeart ssrate ss101 ssBPM, ssoxygen sssaturation
ss90%. ssBlood sspressure ss145/89, sstemperature ss100.2 ssF, ssrespiratory ssrate ss28
ssBPM. ss
0500: ssPlacedthe ssclient ssin sssemi-Fowlers ssposition. ssNo ssimprovement ssin ssoxygen
sssaturation sson ss3L ssnasal sscannula...
(Which ssare ssthe ssthree ssmost ssimportant ssgoals?)
A) ssThe ssclient sswill ssremain ssfree ssof ssskin ssbreakdown.
B) ssThe ssclient sswill sshave ssquit sssmoking.
C) ssThe ssclient sswill ssbe ssafebrile ssfor ss24 sshours.
D) ssThe ssclient sswill ssmaintain ssoxygen sssaturation ssof ss96% sswithout sssupplemental
ssoxygen.
E) ssThe ssclient sswill ssreport sspain ssless ssthan ss3/10. ss- ssANS-B) ssThe ssclient sswill
sshave ssquit sssmoking.
C) ssThe ssclient sswill ssbe ssafebrile ssfor ss24 sshours.
E) ssThe ssclient sswill ssreport sspain ssless ssthan ss3/10.
QUESTIONS WITH COMPLETE
ANSWERS
When sspreparing ssto ssadminister ssa ssprescribed ssmedication ssto ssa sshomeless ssclient
ssat ssa sscommunity sspsychiatric ssclinic. ssThe ssclient sstells ssthe ssnurse ssthat ssthe
ssusual ssdosage sstaken ssis ssdifferent ssfrom ssthe ssdose ssthe ssnurse ssis ssgiving.
ssWhich ssaction ssshould ssthe ssnurse sstake? ss
A) ssInform ssthe ssclient ssthat sshe ssmay ssrefuse ssthe ssmedication ssand ssdocument
sswhether ssor ssnot ssthe ssclient sstakes ssit. ss
B) ssWithhold ssthe ssmedication ssuntil ssthe ssdosage sscan ssbe ssconfirmed. ss
C) ssExplain ssto ssthe ssclient ssthat ssthe ssdosage sshas ssbeen sschanged. ss
D) ssTell ssthe ssclient ssto sstake ssthe ssmedication ssthen ssverify ssthe ssdosage ssat ssthe
ssnext sshealthcare ssteam ssmeeting. ss- ssANS-B) ssWithhold ssthe ssmedication ssuntil ssthe
ssdosage sscan ssbe ssconfirmed.
The sscharge ssnurse ssis ssmaking ssassignments ssfor ssone sspractical ssnurse ssand
ssthree ssregistered ssnurses sswho ssare sscaring ssfor ssneurologically sscompromised
ssclients. ssWhich ssclient sswith sswhich sschange ssin ssstatus ssis ssbest ssto ssassign ssto
ssthe ssPN? ss
A) ssSubdural sshematoma sswhose ssblood sspressure sschanged ssfrom ss150/80 ssto
ss170/60.
B) ssViral ssmeningitis sswhose sstemperature sschange ssfrom ss101 ssS ssto ss102F. ss
C) ssDiabetic ssketo ssacidosis sswho ssis ssGlasgow sscoma ssscale ssscore sschanged
ssfrom ss10 ssto ss7. ss
D) ssMyxedema, sswhose ssblood sspressure sschange ssfrom ss80/50 ssto ss70/40. ss- ssANS-
B) ssViral ssmeningitis sswhose sstemperature sschange ssfrom ss101 ssS ssto ss102F.
The ssnurse ssis sscaring ssfor ssa ssclient sswith sspneumonia sswho ssnow ssdevelops ssinitial
sssigns ssof ssseptic ssshock ssand ssmulti ssorgan ssfailure. ssThe sshealthcare ssprovider
ssprescribes ssa sssepsis ssprotocol. ssWhich ssintervention ssis ssmost ssimportant ssfor ssthe
ssnurse ssto ssinclude ssin ssthe ssplan ssof sscare? ss
A) ssMaintain ssstrict ssintake ssand ssoutput. ss
,B) ssKeep sshead ssof ssbed ssraised ss45°. ss
C) ssExcess sswarmth ssof ssextremities. ss
D) ssMonitor ssblood ssglucose sslevel. ss- ssANS-A) ssMaintain ssstrict ssintake ssand
ssoutput.
And ssadolescent ssclient ssis ssadmitted ssto ssthe sshospital ssbecause ssof sswriting ssa
sssuicide ssnote ssto ssa ssteacher ssat ssschool. ssOn ssthe sssecond ssday ssof
sshospitalization, ssthe ssnurse ssasked ssthe ssclient ssto ssmeet sswith ssthe sstreatment
ssteam. ssAfter ssthe ssteam ssmeeting, ssthe ssclient ssleaves ssin sstears ssand ssgoes ssto
sstheir ssroom. ssWhich ssnursing ssintervention ssis ssbest? ss
A) ssLet ssthe ssclient ssrest ssquietly ssin sstheir ssroom ssfor ssa sswhile. ss
B) ssExplore ssthe ssclients ssgoals ssand ssdesire ssfor sstreatment. ss
C) ssAsk ssthe sstreatment ssteam ssabout ssthe ssclients ssbehavior. ss
D) ssGo ssto ssthe ssclients ssroom ssand ssask sswhat sshappened. ss- ssANS-D) ssGo ssto
ssthe ssclients ssroom ssand ssask sswhat sshappened.
The sshealthcare ssprovider ssprescribes ssdalteparin ss200 ssunits ssper sskilogram
sssubcutaneous ssonce ssa ssday ssfor ssa ssclient sswho ssweighs ss154 sspounds. ssThe
ssmedication ssis ssavailable ssand ss25,000 ssunits ssper ssmilliliter ssvial. ssHow ssmany
ssmilliliters ssshould ssthe ssnurse ssadminister? ss(Enter ssnumerical ssvalue ssonly. ssIf
ssrounding ssis ssrequired, ssround ssto ssthe ssnearest ss10th.) ss- ssANS-0.6
NGN: ssThe ssclient ssis ssa ss49-year-old ssmale sswho ssreports ssflu sslike sssymptoms
ssincluding ssfever ssand sschest sscongestion ssfor ssfour ssdays. ssHe sscame ssto ssthe
ssemergency ssdepartment sslast ssnight sswhen sshe sswas sshaving ssmore ssdifficulty
ssbreathing sshe sshas ssa sshistory ssof ss1/2 sspack ssa ssday sscigarette sssmoking ssfor ss20
ssyears. ssHe sshas ssno sssignificant ssmedical ssor sssurgical sshistory. ss
Which sstwo ssorders ssshould ssthe ssnurse sscomplete ssfirst? ss
A) ssSputum ssculture. ss
B) ssStart ssoxygen ss3 ssL ssper ssminute ssvia ssnasal sscannula. ss
C) ssPlace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor. ss
D) ssChest ssx-ray. ss
E) ssAcetominophen ss350 ssmg ssPO ssevery sssix sshours ssfor sstemperature sscontrol. ss
F) ssRun ss0.9% sssodium sschloride ssIV ssinfusion ssat ss150 ssmL ssper sshour. ss
G) ssStart ssperipheral ssIV. ss
H) ssNPO. ss- ssANS-B) ssStart ssoxygen ss3 ssL ssper ssminute ssvia ssnasal sscannula. ss
C) ssPlace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor.
NGN: ss0330: ssplace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor, ssNPO, sssputum
ssculture, ssstart ssa ssperipheral ssIV ssinfusion, ssstart ssoxygen ss3 ssL ssper ssminute ssvia
ssnasal sscannula, ssbegin ss0.9% sssodium sschloride ssIV ssinfusion ssat ss150 ssmL ssper
sshour, ssacetaminophen ss350 ssmg ssPO ssevery sssix sshours ssfor sstemperature.
To ssstart ssthe ssclient sson ssoxygen ssas ssordered sswhich ssitems ssshould ssthe ssnurse
sscollects ssfrom ssthe sssupply ssroom? ssSATA ss
,A) sshumidifier ssbottle. ss
B)Suction sscanister. ss
C)Sterile sswater. ss
D) ssNasal sscannula. ss
E) ssFlow ssmeter. ss
F) ssLambs sswool. ss
G) ssTape. ss- ssANS-D) ssNasal sscannula. ss
E) ssFlow ssmeter.
NGN: ssstates, ssI ssam ssfeeling ssextremely ssanxious ssright ssnow. ssThe ssclient sshas
ssdecreased ssbreath sssounds ssin ssthe ssleft sslower sslow. ssHis ssmucus ssmembranes
ssare ssdry. ssHe sshas ssa ssproductive sscough sswith ssthick, ssyellow sssecretions. ssHis
sscapillary ssrefill ssis ssfour ssseconds. ssVital sssigns, sstemperature ss100.2. ssHeart ssrate
ss101 ssbpm, ssrespiratory ssrate ss28 ssbreaths ssper ssminute, ssblood sspressure ss145/89,
ssoxygen sssaturation ss90% sson ssroom ssair.
(for sseach ssbody sssystem ssclick ssto ssspecify ssthe ssassessment ssfindings ssthat
ssindicates sshypoxia)
Cardiovascular: ssheart ssrate ss100 ssbpm, sscapillary ssrefill ssfor ssseconds, ssblood
sspressure ss145/89.
Neurological: ssanxious, ssawake ssand ssalert, ssrestless.
Respiratory: ssoxygen sssaturation ss90% sson ssroom ssair, ssrespiratory ssrate ss28 ssbpm,
ssproductive sscough. ss- ssANS-Cardiovascular: sscapillary ssrefill ssfor ssseconds, ssblood
sspressure ss145/89.
Neurological: ssanxious, ssrestless.
Respiratory: ssoxygen sssaturation ss90% sson ssroom ssair, ssrespiratory ssrate ss28 ssbpm.
NGN: ssThe ssclient ssis ssa ss49-year-old ssmale sswho ssreports ssflu sslike sssymptoms
ssincluding ssfever ssand sschest sscongestion ssfor ssfour ssdays. ssHe sscame ssto ssthe
ssemergency ssdepartment sslast ssnight sswhen sshe sswas sshaving ssmore ssdifficulty
ssbreathing sshe sshas ssa sshistory ssof ss1/2 sspack ssa ssday sscigarette sssmoking ssfor ss20
ssyears. ssHe sshas ssno sssignificant ssmedical ssor sssurgical sshistory. ss
The ssnurse ssshould ssplace ssthe ssclient ssin ssa ss_______________ ssposition ssto
sspromote ss_____________. ss- ssANS-Semi-Fowler ss, sslung ssexpansion.
NGN: ssOrders: ss0330: ssplace ssthe ssclient sson ssa sscardio ssrespiratory ssmonitor,
ssNPO, sssputum ssculture, ssstart ssa ssPIV, ssstart ssoxygen ss3L ssvia ssnasal sscannula,
ssnormal sssaline ss150 ssML ssper sshour, ssacetaminophen ss350mg ssPO ssevery sssix
sshours ssfor sstemp ssgreater ssthan ss101F, sschest ssx-ray.
0500: ssOxygen ss8Lvia sssimple ssfacemask, sstitrate ssto sskeep ssoxygen sssaturation
ssgreater ssthan ss94%.
, (mark sswhether ssthe ssstatements ssby ssthe ssnew ssgrad ssnurse ssindicate
ssunderstanding ssor ssno ssunderstanding ssof ssthe ssuse ssof ssfacemask ssin ssthe sscare
ssof ssthis ssclient)
-I ssshould ssclean ssthe ssfacemask ssonce ssper ssshift.
-The ssclient ssshould sstake ssa ss1 ssto ss2 ssminute ssbreak ssfrom ssthe ssfacemask sseach
sshour.
-I ssshould ssput ssgauze ssunder ssthe sselastic ssstraps ssover ssthe ssears.
-I sscan ssadjust ssthe ssoxygen sslevel sson ssthe ssflow ssmeter ssto sskeep ssthe ssclients
ssoxygen sssaturation ssgreater ssthan ss94%.
-The ssmask ssshould sscover ssonly ssthe ssmouth ssand ssleave ssthe ssnose ssopen ssfor
ssexpiration.
-I ssshould ssplace ssthe ssmask ssfirst ssover ssthe ssnose ssand ssthen sscover ssthe ssmouth.
ss- ssANS--I ssshould ssclean ssthe ssfacemask ssonce ssper ssshift. ss(UNDERSTANDING)
-The ssclient ssshould sstake ssa ss1 ssto ss2 ssminute ssbreak ssfrom ssthe ssfacemask sseach
sshour. ss(NOT ssUNDERSTANDING)
-I ssshould ssput ssgauze ssunder ssthe sselastic ssstraps ssover ssthe ssears. ss(NOT
ssUNDERSTANDING ss????)
-I sscan ssadjust ssthe ssoxygen sslevel sson ssthe ssflow ssmeter ssto sskeep ssthe ssclients
ssoxygen sssaturation ssgreater ssthan ss94%. ss(UNDERSTANDING)
-The ssmask ssshould sscover ssonly ssthe ssmouth ssand ssleave ssthe ssnose ssopen ssfor
ssexpiration. ss(NOT ssUNDERSTANDING)
-I ssshould ssplace ssthe ssmask ssfirst ssover ssthe ssnose ssand ssthen sscover ssthe ssmouth.
ss(UNDERSTANDING)
NGN: ssNurses ssNotes: ss0400, ssthe ssclient ssis ssawake ssand ssalert ssbut ssrestless. ssHe
ssstates ssI ssam ssfeeling ssextremely ssanxious ssright ssnow. ssThe ssclient sshas
ssdecreased ssbreath sssounds ssin ssthe ssleft sslower sslobe. ssHis ssmucus ssmembranes
ssare ssdry. ssHe sshas ssa ssproductive sscough sswith ssthick, ssyellow sssecretions. ssHis
sscapillary ssrefill ssis ssfour ssseconds. ssHeart ssrate ss101 ssBPM, ssoxygen sssaturation
ss90%. ssBlood sspressure ss145/89, sstemperature ss100.2 ssF, ssrespiratory ssrate ss28
ssBPM. ss
0500: ssPlacedthe ssclient ssin sssemi-Fowlers ssposition. ssNo ssimprovement ssin ssoxygen
sssaturation sson ss3L ssnasal sscannula...
(Which ssare ssthe ssthree ssmost ssimportant ssgoals?)
A) ssThe ssclient sswill ssremain ssfree ssof ssskin ssbreakdown.
B) ssThe ssclient sswill sshave ssquit sssmoking.
C) ssThe ssclient sswill ssbe ssafebrile ssfor ss24 sshours.
D) ssThe ssclient sswill ssmaintain ssoxygen sssaturation ssof ss96% sswithout sssupplemental
ssoxygen.
E) ssThe ssclient sswill ssreport sspain ssless ssthan ss3/10. ss- ssANS-B) ssThe ssclient sswill
sshave ssquit sssmoking.
C) ssThe ssclient sswill ssbe ssafebrile ssfor ss24 sshours.
E) ssThe ssclient sswill ssreport sspain ssless ssthan ss3/10.
