HESI Case Study: COPD with
Pneumonia
The physical examination reveals the following:
Vital signs: temperature 101.6° F (38.6° C),
heart rate 110 beats/minute, respirations 32
breaths/minute, blood pressure 132/78 mmHg.
Respirations shallow and labored, with use of
respiratory accessory muscles.
Increased anteroposterior (AP) diameter of the
chest.
Skin dry and warm to touch, with inelastic skin
turgor, and fingernail clubbing present.
1.Which assessment is most important for the
nurse to complete next? - ANSWER-Auscultate
breath sounds.
2. With a diagnosis of pneumonia, which
assessment finding warrants immediate
intervention by the nurse? - ANSWER-Oxygen
saturation 90%.
pH 7.25 7.35 to 7.45 7.35 to 7.45
pCO2 58 35 to 45 mmHg 35 to 45 mmHg
HCO3 26 21 to 28 mEq/L 21 to 28 mmol/L
, pO2 87 80 to 100 mmHg 80 to 100 mmHg
3. The ABG results indicate that the client is
experiencing which acid-base imbalance? -
ANSWER-Respiratory acidosis.
4. Which nursing problem has the highest
priority when the nurse is planning care for the
client? - ANSWER-Ineffective airway clearance.
5. Which assessment finding warrants
immediate intervention by the nurse? -
ANSWER-Kussmal respirations.
6. Which nursing action should be implemented
before the prescribed levofloxacin is
administered? - ANSWER-Obtain a sputum
culture with sensitivity.
7. The levofloxacin 500 mg IVPB is supplied in
100 mL of 5% dextrose to be delivered over 60
minutes. There is no IV pump available, so the
nurse will infuse the antibiotic by gravity. The
drop factor on the tubing is 20 gtts/mL. The
nurse should set the IVPB to infuse at how
many gtts per min? (Enter numerical value only.
Pneumonia
The physical examination reveals the following:
Vital signs: temperature 101.6° F (38.6° C),
heart rate 110 beats/minute, respirations 32
breaths/minute, blood pressure 132/78 mmHg.
Respirations shallow and labored, with use of
respiratory accessory muscles.
Increased anteroposterior (AP) diameter of the
chest.
Skin dry and warm to touch, with inelastic skin
turgor, and fingernail clubbing present.
1.Which assessment is most important for the
nurse to complete next? - ANSWER-Auscultate
breath sounds.
2. With a diagnosis of pneumonia, which
assessment finding warrants immediate
intervention by the nurse? - ANSWER-Oxygen
saturation 90%.
pH 7.25 7.35 to 7.45 7.35 to 7.45
pCO2 58 35 to 45 mmHg 35 to 45 mmHg
HCO3 26 21 to 28 mEq/L 21 to 28 mmol/L
, pO2 87 80 to 100 mmHg 80 to 100 mmHg
3. The ABG results indicate that the client is
experiencing which acid-base imbalance? -
ANSWER-Respiratory acidosis.
4. Which nursing problem has the highest
priority when the nurse is planning care for the
client? - ANSWER-Ineffective airway clearance.
5. Which assessment finding warrants
immediate intervention by the nurse? -
ANSWER-Kussmal respirations.
6. Which nursing action should be implemented
before the prescribed levofloxacin is
administered? - ANSWER-Obtain a sputum
culture with sensitivity.
7. The levofloxacin 500 mg IVPB is supplied in
100 mL of 5% dextrose to be delivered over 60
minutes. There is no IV pump available, so the
nurse will infuse the antibiotic by gravity. The
drop factor on the tubing is 20 gtts/mL. The
nurse should set the IVPB to infuse at how
many gtts per min? (Enter numerical value only.
