Actual Questions and Answers, Complete 100

2024 HESI Case Studies Respiratory Actual Questions and Answers, Complete 100%

• Mr. Winston Winchell is a 70-year-old Black man. He has a history of

emphysema and has been admitted to an inpatient medical unit with an acute respiratory infection. The nurse prepares to complete the client's admission assessment after Mr. Winchell's transfer from the emergency department (ED).To ensure the client's respiratory status is stable upon his arrival on the medical unit, the nurse should complete which assessment first?

• Breath sounds
• Oxygen Saturation
• Level of Fatigue

D. Chest Excursion:

Answer:

• Oxygen Saturation

• The initial assessment of Mr. Winchell continues. The nurse measure the

client's vital signs. Mr. Winchell's respiratory rate is 32 breaths per minute.What follow-up assessment data should the nurse obtain first?

• Cigarette smoking history.
• Use of accessory muscles
• Cultural health beliefs

D. Color of sputum:

Answer:

• Use of accessory muscles

• The nurse applies oxygen at 2 liters per minute via nasal cannula and ensures

that the client is comfortable. His oxygen saturation is stable at 95%, and his respiratory rate decreases to 24 breaths per minute. Mr. Winchell reports that he feels able to continue with the admission interview and assessment.After answering a few questions, the client begins to cough. What assessment should the nurse perform?

• Assess for the presence of nail bed clubbing
• Review oral fluid intake for the last 24 hours
• Observe for dryness of the oral mucosa

D. Note the amount and appearance of any sputum:

Answer:

• Note the amount and appearance of any sputum

• Mr. Winchell's cough is non-productive. 1 / 2

After Mr. Winchell stops coughing, the nurse continues the interview. To assess the client's history related to dyspnea on exertion (DOE), what question should the nurse ask Mr. Winchell?

• "Do you become short of breath while lying flat?"
• "What activities cause you to feel short of breath?"
• "How frequently do you experience difficulty breathing?"

D "Are you having trouble catching your breath now?":

Answer:

• "What activities cause you to feel short of breath?"

• The nurse asks Mr. Winchell about his history of cigarette smoking. Mr.

Wichell tells the nurse that he smoked two packs of cigarettes per day for more than 40 years, but then he quit smoking 10 years ago. He then looks away and remarks that he is very fatigued from answering all the interview questions.How should the nurse respond?

• Continue the interview and assessment, avoid further questions related to

cigarette smoking.

• Restrict visitors so that the client can rest, and return later to complete the

interview and assessment

• Advise the client to rest in bed wile the nurse performs a physical assessment

of the client

• Document that the physical assessment could not be performed because

of the client's level of fatigue:

Answer:

• Advise the client to rest in bed wile the nurse performs a physical assessment of

the client

• Wile Mr. Winchell rests, the nurse continues the physical assessment. The

nurse observes the appearance of Mr. Winchell's thorax and notes that the

ratio of his anteroposterior and transverse chest diameters is 1:1.

How should this finding be documented?

• Within normal limits
• Funnel chest
• Barrel chest

D. Thoracic scoliosis:

Answer:

• Barrel chest

• The nurse observes Mr. Winchell for outward signs of hypoxemia. The nurse
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