Nursing

12/15/23, 3:38 PM Linus Fuller 68-years-old: Attempt review

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Dashboard / Medical Care Unit / Linus Fuller 68-years-old

12/15/23, 3:38 PM Linus Fuller 68-years-old: Attempt review

https://learning.nursethink.com/mod/quiz/review.php?attempt=1902461&cmid=1038 2/4

Started on Friday, 15 December 2023, 2:19 PM

State Finished

Completed on Friday, 15 December 2023, 2:38 PM

Time taken 19 mins 29 secs

Grade 100.00 out of 100.00

Question Complete Mark 33.34 out of 33.34

Name: Linus Fuller Age: 68 years Provider: B. Church MD

Code Status: Full Code Admit Wt: 225 lbs (102.1 kg) BMI: 32.3

Allergies: latex

11/28 0730

Neuro/Cognitive: Alert, oriented x 4. Speech: 4-5 word sentences. Speaks without difficulty. Clear.

Cardiovascular: S1 and S2 sounds present. HR regular and even. No edema noted.

Respiratory: Breathing nonlabored, even. Lung sounds with inspiratory/expiratory wheezes and rhonchi throughout all lung fields. Dry persistent cough. +rhinorrhea, sore throat.

Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, nontender. +nausea.

Drains/Lines: 20-gauge IV Right hand. Patent, intact. Dressing clean, dry, intact.

Before answering this question, review the client’s health information in the EHR. Identify cues associated with the client's problem. Select to highlight.

Nursing Assessment – 11/28 0730: Neuro/Cognitive: Alert, oriented x 4. Speech: 4-5 word sentences. Speaks without difficulty. Clear.

Cardiovascular: S1 and S2 sounds present. HR regular and even. No edema noted.

Respiratory: Breathing nonlabored, even. Lung sounds with inspiratory/expiratory wheezes and rhonchi throughout all lung fields. Dry persistent cough. +rhinorrhea, sore throat.

Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, nontender. +nausea

Drains/Lines: 20-gauge IV Right hand. Patent, intact. Dressing clean, dry, intact.

Question Complete Mark 33.33 out of 33.33

1

Nursing Flowsheets Other

NURSING ASSESSMENT & NOTES

Consider:

1. What objective data will the client likely report?

2. Why may the client be experiencing nausea?

3. Compare and contrast signs and symptoms of influenza and an emphysema exacerbation.

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12/15/23, 3:38 PM Linus Fuller 68-years-old: Attempt review

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Name: Linus Fuller Age: 68 years Provider: B. Church MD

Code Status: Full Code Admit Wt: 225 lbs (102.1 kg) BMI: 32.3

Allergies: latex

Before answering this question, review the client's health information in the EHR. Identify the correct actions the nurse should take. Select one option in each row.

Question Complete Mark 33.33 out of 33.33

Name: Linus Fuller Age: 68 years Provider: B. Church MD

Code Status: Full Code Admit Wt: 225 lbs (102.1 kg) BMI: 32.3

Allergies: latex

11/28

0700

Nursing Note: Bedside shift report received from K. Williams, RN. Client asleep in bed. Breathing regular,

even. 0935: The client titrated off oxygen after consistently maintaining a SpO of 98% on 2 L. Client does not

Nursing Flowsheets Provider MAR Other

NURSING ASSESSMENT & NOTES

11/28 0700

Nursing Note: Bedside shift report received from K. Williams, RN. Client asleep in bed. Breathing regular, even. 0935: The client titrated off oxygen after consistently maintaining a SpO of 98% on 2 L. Client does not wear oxygen at baseline.2

11/28 0730

Neuro/Cognitive: Alert, oriented x 4. Speech: 4-5 word sentences. Speaks without difficulty. Clear.

Cardiovascular: S1 and S2 sounds present. HR regular and even. No edema noted.

Respiratory: Breathing nonlabored, even. Lung sounds with inspiratory/expiratory wheezes and rhonchi throughout all lung fields. Dry persistent cough. +rhinorrhea, sore throat.

Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, nontender. +nausea.

Drains/Lines: 20-gauge IV Right hand. Patent, intact. Dressing clean, dry, intact.

11/28 0940

Nursing Note: Client SpO continues at 95% on room air.2

Correct Incorrect

Cohort client with a positive rhinovirus roommate.

Apply mask and face shield prior to entry.

Complete an incident report for medication error.

Titrate oxygen to 4 L.

Wash hands after leaving precautions room.

Administer influenza vaccination.

Administer acetaminophen.

Consider:

1. What is the benefit of cohorting isolation clients? What are some concerns?

2. What are other contraindications to administering an influenza vaccine?

3. Compare and contrast airborne precautions and droplet precautions.

3

Nursing Flowsheets Provider MAR Other

NURSING ASSESSMENT & NOTES

2

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12/15/23, 3:38 PM Linus Fuller 68-years-old: Attempt review

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wear oxygen at baseline.

11/28

0730

Neuro/Cognitive: Alert, oriented x 4. Speech: 4-5 word sentences. Speaks without difficulty. Clear.

Cardiovascular: S1 and S2 sounds present. HR regular and even. No edema noted.

Respiratory: Breathing nonlabored, even. Lung sounds with inspiratory/expiratory wheezes and rhonchi

throughout all lung fields. Dry persistent cough. +rhinorrhea, sore throat.

Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, nontender. +nausea.

Drains/Lines: 20-gauge IV Right hand. Patent, intact. Dressing clean, dry, intact.

11/28

0940

Nursing Note: Client SpO continues at 95% on room air.

11/28

1700

Nursing Note: UAP notifies RN that client is reporting shortness of breath after returning from the bathroom. At

bedside, client noted to be using 2-3 word sentences. Pale blue tint to lips. +intercostal retractions. Audible

wheezing noted. SpO : 78% on room air. Placed on 4 L via nasal cannula and increases to 90%. Respiratory

paged.

11/28

1705

Nursing Note: 95% on 4 L via nasal cannula. Client being administered breathing treatment.

Before answering this question, review the client's health information in the EHR. Identify actions or statements by the client

that needs follow-up education by the nurse. Use the drop-down menus in each group to select the correct statement.

Illness Management:

Breathing Exercises:

Oxygen Therapy:

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2

"My 5-month-old granddaughter is breastfed, so she has immunity, and I can see her."

"I will take short quick breaths when using my inhaler."

"I can put the oxygen cannula in my mouth to give my nose a break."

Consider:

1. What teaching should the nurse provide a client going home on oxygen therapy?

2. What additional teaching should the nurse provide to this client upon discharge home?

3. Teach a classmate how to do pursed-lip breathing.

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