SR Hildegard Lowe, Wight
Goodman,Ramona Stukes Exam
Questions & Answers (Grade A+)
Hildegard Lowe is a 68-year-old female, admitted through the
emergency department (ED) for a persistent cough. The client is
alert and cooperative, receiving oxygen at 2 L/min via nasal canula.
IV 0.9% normal saline infusing at 125 mL/hr. Chest x-ray upon
admission indicates right middle lobe pneumonia. Vital signs are
blood pressure 128/86 mmHg, pulse 105/min, respirations 32/min,
temperature 37.7° C (99.8° F), and oxygen saturation 93% on 2
L/min via nasal canula. Laboratory results from the ED are pending.
Plan of care is antibiotic therapy and supplemental oxygen therapy.
Client had fall that resulted in an open reduction internal fixation of
the right ulna 3 months ago. The client has a history of age-related
macular degeneration and osteoporosis. The client takes
alendronate for osteoporosis. The client is widowed and has one
child who is on their way from out of state who will be arriving
sometime today. The c -
correct answer ✅Maslow's Hierarchy of Needs- high
Airway, Breathing, Circulation- high
Safety and Risk Reduction- high
Urgent vs Nonurgent- high
,SR Hildegard Lowe, Wight
Goodman,Ramona Stukes Exam
Questions & Answers (Grade A+)
Chronic vs Acute/Stable vs Unstable- low
Hildegard Lowe
Initial Nursing Assessment
The nurse reviews the information received in the report and enters
the client's room to perform a physical assessment. Upon
assessment, the client is alert and oriented to person, place, time,
and event. Pupils are equal, round, reactive to light, and
accommodation. IV to left forearm is infusing 0.9% normal saline at
125 mL/hr. Crackles auscultated bilaterally with lung sounds
diminished in the right middle lobe. Dulled percussion is noted over
right middle lung base. The client is tachypneic and is receiving
oxygen at 2 L/min via nasal canula. Client has a productive cough
and is expectorating green-yellow sputum. The client rates pain as a
4 on a 0 to 10 pain scale during coughing episodes. S1S2 heart
tones are noted. All pulses palpable. The abdomen is soft and
nontender upon palpation. Bowel sounds are active in all four
quadrants. The client is lying in semi-Fowler's -
correct answer ✅Physiological: Comfort
, SR Hildegard Lowe, Wight
Goodman,Ramona Stukes Exam
Questions & Answers (Grade A+)
Physiological: Gas Exchange
Physiological: Infection
Physiological: Inflammation
Physiological: Perfusion
Hildegard Lowe
The assistive personnel reports current vital signs to the nurse.
Blood pressure is 140/92 mmHg, heart rate 110/min, respirations
36/min, temperature 37.7° C (99.8° F), and oxygen saturation 88%
on 2 L/min via nasal canula. When the nurse enters the client's
room, the client is pleasant and cooperative but appears anxious.
Which of the following actions should the nurse take? (Select all
that apply.) -
correct answer ✅Teach the client how to use an incentive
spirometer.
Instruct the client to cough and deep breathe every 2 hr.
Goodman,Ramona Stukes Exam
Questions & Answers (Grade A+)
Hildegard Lowe is a 68-year-old female, admitted through the
emergency department (ED) for a persistent cough. The client is
alert and cooperative, receiving oxygen at 2 L/min via nasal canula.
IV 0.9% normal saline infusing at 125 mL/hr. Chest x-ray upon
admission indicates right middle lobe pneumonia. Vital signs are
blood pressure 128/86 mmHg, pulse 105/min, respirations 32/min,
temperature 37.7° C (99.8° F), and oxygen saturation 93% on 2
L/min via nasal canula. Laboratory results from the ED are pending.
Plan of care is antibiotic therapy and supplemental oxygen therapy.
Client had fall that resulted in an open reduction internal fixation of
the right ulna 3 months ago. The client has a history of age-related
macular degeneration and osteoporosis. The client takes
alendronate for osteoporosis. The client is widowed and has one
child who is on their way from out of state who will be arriving
sometime today. The c -
correct answer ✅Maslow's Hierarchy of Needs- high
Airway, Breathing, Circulation- high
Safety and Risk Reduction- high
Urgent vs Nonurgent- high
,SR Hildegard Lowe, Wight
Goodman,Ramona Stukes Exam
Questions & Answers (Grade A+)
Chronic vs Acute/Stable vs Unstable- low
Hildegard Lowe
Initial Nursing Assessment
The nurse reviews the information received in the report and enters
the client's room to perform a physical assessment. Upon
assessment, the client is alert and oriented to person, place, time,
and event. Pupils are equal, round, reactive to light, and
accommodation. IV to left forearm is infusing 0.9% normal saline at
125 mL/hr. Crackles auscultated bilaterally with lung sounds
diminished in the right middle lobe. Dulled percussion is noted over
right middle lung base. The client is tachypneic and is receiving
oxygen at 2 L/min via nasal canula. Client has a productive cough
and is expectorating green-yellow sputum. The client rates pain as a
4 on a 0 to 10 pain scale during coughing episodes. S1S2 heart
tones are noted. All pulses palpable. The abdomen is soft and
nontender upon palpation. Bowel sounds are active in all four
quadrants. The client is lying in semi-Fowler's -
correct answer ✅Physiological: Comfort
, SR Hildegard Lowe, Wight
Goodman,Ramona Stukes Exam
Questions & Answers (Grade A+)
Physiological: Gas Exchange
Physiological: Infection
Physiological: Inflammation
Physiological: Perfusion
Hildegard Lowe
The assistive personnel reports current vital signs to the nurse.
Blood pressure is 140/92 mmHg, heart rate 110/min, respirations
36/min, temperature 37.7° C (99.8° F), and oxygen saturation 88%
on 2 L/min via nasal canula. When the nurse enters the client's
room, the client is pleasant and cooperative but appears anxious.
Which of the following actions should the nurse take? (Select all
that apply.) -
correct answer ✅Teach the client how to use an incentive
spirometer.
Instruct the client to cough and deep breathe every 2 hr.
