Question

A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute. Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.

Answer 1

Correct Answers:

Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
Stat 2 views chest x-ray.
Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Rationale :

💠 Oxygen saturation of 94% is slightly below the normal threshold; initiating 2–4 L/min of nasal oxygen supports oxygenation and prevents further desaturation.

💠 A chest X-ray is a critical diagnostic tool to assess for respiratory or cardiac causes of fever and increased heart rate—such as pneumonia or pulmonary edema.

💠 Ordering a CBC, BMP, and blood cultures provides valuable data on infection, inflammation, and organ function—especially in a patient showing signs of systemic illness.

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Answer 2

Correct Answers:

Describe the use of an elimination diet to find trigger foods.

Rationale :

🔶 An elimination diet involves removing common trigger foods and gradually reintroducing them to observe for symptoms—making it highly effective for individualized care.

🔶 This strategy empowers the client to identify specific intolerances, such as dairy, gluten, or spicy foods, without compromising nutritional status unnecessarily.

🔶 It supports symptom relief while promoting a balanced, nutrient-dense diet, unlike unnecessary blanket restrictions.

🔶 Education on food triggers allows for long-term symptom control in Crohn’s disease management.

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Answer 3

Correct Answers:

Risk for aspiration related to difficulty swallowing.

Rationale :

🔷 Dysphagia, or difficulty swallowing, places the patient at high risk for aspiration pneumonia, which is potentially life-threatening.

🔷 This complication is more urgent than pain or nutrition concerns, as it involves the airway and respiratory compromise.

🔷 The nurse must prioritize interventions that reduce the risk of aspiration, such as modifying food consistency and maintaining upright positioning.

🔷 Prompt recognition and prevention of aspiration can significantly reduce morbidity and mortality in patients with esophageal cancer.

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Answer 4

Correct Answers:

Check serum creatinine.

Rationale :

🟢 Vancomycin is known for its nephrotoxic potential, making it essential to assess kidney function before administration.

🟢 A baseline serum creatinine level helps determine how efficiently the drug will be cleared by the kidneys.

🟢 Administering vancomycin without checking renal function could result in toxic drug accumulation and acute kidney injury.

🟢 Dosing adjustments are based on renal clearance to ensure both safety and therapeutic effectiveness.

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Answer 5

Correct Answers:

Pneumonia

Rationale :

🟥 The nurse should recognize that the client’s current diagnosis is pneumonia, as indicated in the report.

🟥 Documentation should reflect the client’s actual condition, which guides current care and interventions.

🟥 Referencing unrelated history (e.g., total knee replacement) or ongoing medication use is less clinically relevant in this context.

🟥 Accurate clinical documentation promotes effective interdisciplinary communication and care continuity.

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Answer 6

Correct Answers:

Pneumonia

Rationale :

🔴 The chest X-ray reveals progression of infiltrates, especially in the lower lobes—this is consistent with a diagnosis of pneumonia.

🔴 Pneumonia often causes new or worsening infiltrates, fever, cough, and abnormal breath sounds.

🔴 It typically develops over hours to days, matching the progression seen in this case.

🔴 The nurse must recognize radiographic changes as a sign of active infection requiring intervention.

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Answer 7

Correct Answers:

Advise the patient that healing typically takes several weeks to occur.

Rationale :

🟨 Proton pump inhibitors (PPIs) like lansoprazole may take several weeks to heal the esophageal mucosa in GERD or erosive esophagitis.

🟨 Clients should be educated to continue therapy even if immediate relief is not observed.

🟨 Premature discontinuation could result in symptom recurrence or worsening of esophageal damage.

🟨 Setting realistic expectations supports adherence to the treatment plan and enhances outcomes.

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Answer 8

Correct Answers:

Diabetes Mellitus

Rationale :

🟪 An HbA1c level of 8.29% exceeds the diagnostic threshold for diabetes (≥6.5%).

🟪 HbA1c reflects average blood glucose over the past 2–3 months, offering a reliable long-term glycemic measure.

🟪 The patient’s values also show a rising trend, suggesting worsening diabetes control.

🟪 This warrants timely intervention to prevent complications such as neuropathy, nephropathy, and retinopathy.

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Answer 9

Correct Answers:

Corneal abrasion

Rationale :

🟤 The nurse must verify whether the patient has a corneal abrasion before administering ophthalmic ketorolac.

🟤 Ketorolac, a topical NSAID, is contraindicated in corneal injury as it may impair healing and increase the risk of corneal melting.

🟤 The priority is to review the health record to ensure safe medication administration.

🟤 This prevents iatrogenic harm and ensures the eye's epithelial layer is not compromised further.

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Answer 10

Correct Answers:

Culture for sensitive organisms.

Rationale :

🔵 Wound drainage cultures help identify the specific pathogen causing an infection, enabling targeted antibiotic treatment.

🔵 Empirical antibiotic use without culture data may be ineffective or lead to resistance.

🔵 This step is especially important in post-op wounds with signs of infection such as erythema, warmth, and purulent drainage.

🔵 Proper wound assessment and documentation promote accurate diagnosis and effective care planning.

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Hesi RN Adult Health

No.

2 :
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

3 :
The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

4 :
The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

6 :
Patient Data shows that on Day 1, there were no active processes. On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side. What is the likely diagnosis?

7 :
A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

8 :
The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

9 :
A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

10 :
While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

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Hesi RN Adult Health

No.

2 : A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

3 : The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

4 : The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

6 : Patient Data shows that on Day 1, there were no active processes. On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side. What is the likely diagnosis?

7 : A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

8 : The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

9 : A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

10 : While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

2 :
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

3 :
The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

4 :
The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

6 :
Patient Data shows that on Day 1, there were no active processes. On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side. What is the likely diagnosis?

7 :
A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

8 :
The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

9 :
A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

10 :
While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?