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    Hesi RN Fundamentals Proctored Exam 1

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    Question: 1 of 55HESI RN Fundamentals Proctored Exam 1
    A nurse is caring for a client in the intensive care unit. Exhibits Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
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    Actions to Take

    Administer diuretics as prescribed
    Increase oxygen flow rate
    Perform chest physiotherapy
    Administer bronchodilators as prescribed
    Elevate the head of the bed

    Potential Conditions

    Acute respiratory distress syndrome (ARDS)
    Congestive heart failure exacerbation
    Hospital-acquired pneumonia
    Chronic obstructive pulmonary disease (COPD) exacerbation

    Parameters to Monitor

    Oxygen saturation
    Blood pressure
    Respiratory rate
    White blood cell count
    Serum creatinine

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    Explanation
    Most Likely Condition: The client is most likely experiencing Hospital-acquired pneumonia ©. This is indicated by the recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and bilateral infiltrates on the chest X-ray. Actions to Take: Administer IV antibiotics as prescribed (already in the provider’s prescriptions). Perform chest physiotherapy © to help clear the lungs. Parameters to Monitor: Oxygen saturation (A) to ensure the client is maintaining adequate oxygen levels. White blood cell count (D) to monitor the infection and response to antibiotics.
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