AND ANSWERS
An 82-year-old woman drove herself to the emergency department (ED) with reports of chest pain,
shortness of breath, headache, and extreme fatigue. Client states she has been coughing up a lot of
"stuff that looks like egg whites with red string in it." Her chest and abdomen are sore from all the
coughing. She has been unable to eat or sleep well for the past week. Client states that her shortness of
breath has caused such bad anxiety that she can't even concentrate to read the paper. Client is unable
to lay flat but is more comfortable sitting upright in the "tripod position." Client states she has been
having chills and feels like she has been running a fever but does not have a thermometer at home to
check it. - CORRECT ANSWER✅✅Pneumonia
Educate client on incentive spirometer use.
Administer 4L O2 via nasal cannula.
Respiratory Rate.
Intake & Output.
Click to highlight assessment findings that are outside normal limits. - CORRECT ANSWER✅✅Frequent
Cough producing thick yellow mucus along with and inability to speak in complete sentences due to
cough and shortness of breath.
Skin tenting and dry mucous membranes that may indicate dehydration.
HR 104, 92/60
RR 32
86% O2 sat.
Skin color pale
Use of accessory muscles, crackles, chest pain.
Urine color dark
Highlight the Lab results consistent with a bacterial infection. - CORRECT ANSWER✅✅WBC- 15,500
Neutrophils- 9000
Which potential complication is most important for the nurse to monitor in this client? SATA - CORRECT
ANSWER✅✅Impaired gas exchange
Sepsis