Breathing Patterns-HESI Case Study- NRSG317, HESI Case Study:
Mobility, Skin Integrity Hesi Case Study, HESI: Perioperative Care, HESI
Case Study: Pain, fluid balance- HESI case study, Altered Nutrition -
HESI Case Study, Constipation HESI case study
The nurse assesses James' vital signs. His respirations are rapid and shallow. Which is the best
technique for the nurse to use to assess James' respirations accurately?
a) Observe chest expansion for 15 seconds and multiply by 4
b) Encourage James to breathe as deeply and slowly as possible
c) Watch for nasal flaring and count the air exchanges with each movement
d) Place a hand on James' upper abdomen and observe the rise and fall of the chest - correct
answer Place a hand on James' upper abdomen and observe the rise and fall of the chest
James' respiratory rate is 36 breaths/minute. How should the nurse describe James' respiratory
pattern?
a) Eupnea
b) Bradypnea
c) Tachypnea
d) Orthopnea - correct answer Tachypnea
Because of James' dyspnea, the nurse is concerned that he may need to receive oxygen. To
determine the need for supplemental oxygen, which assessment is most important for the
nurse to perform?
a) Measure oxygen saturation
b) Auscultate breath sounds
c) Measure capillary refill
d) Observe chest excursion - correct answer Measure oxygen saturation
In assessing James' breath sounds, the nurse should ask him to perform which action?
a) Hold his breath for fifteen seconds
b) Observe the color of the nailbeds and lips
c) Cough deeply after each breath
d) Breathe deeply through the mouth - correct answer Breathe deeply through the mouth
,To measure capillary refill, the nurse must first perform which action?
a) Count the radial pulse rate
b) Compress the nailbed of one finger until it blanches
c) Obtain a healthcare provider's prescription
d) Elevate the extremity to be assessed - correct answer Compress the nailbed of one finger
until it blances
James' mother states that this is the third time in recent months she had brought him to the ED
with a cough and shortness of breath. The nurse asks the mother how many respiratory or
other infections James has had within the past year. Why does the nurse ask this?
a) To assess for suspected child neglect or abuse
b) To explore the possibility of antibiotic resistance developing
c) To assess for a possible immune deficiency disorder
d) To explore the need for a primary care provider to avoid ED visits - correct answer To assess
for a possible immune deficiency disorder
The nurse plans to measure James' oxygen saturation with a spring-tension finger clip. While
the nurse is explaining this procedure, James asks if it will hurt. Which response is best for the
nurse to provide?
a) "Yes, but the pain will only last a very short time."
b) "No, you will not even know the clip in on your finger."
c) "The clip feels like squeezing your finger with your other hand."
d) "You seem to be worried about experiencing pain." - correct answer "The clip feels like
squeezing your finger with your other hand."
The nurse measures James' oxygen saturation at 88% and capillary refill at 1 second. Breath
sounds are absent in the bases and coarse bilaterally throughout the rest of the lung fields. The
nurse applies a nasal cannula and administers oxygen at 2 liters per minute. Which is the most
important approach for the nurse to use when applying a nasal cannula?
a) Ensure the cannula tubing stays snugly around the ears and under the chin
b) Check that the openings in the nasal prongs are aimed into the nose to prevent skin
breakdown
c) Never allow the humidifier to run out of water
,d) Keep some type of padding around the ears and over the cheekbones - correct answer
Check that the openings in the nasal prongs are aimed into the nose to prevent skin
breakdown.
The nurse measures James' oxygen saturation at 88% and capillary refill at 1 second. Breath
sounds are absent in the bases and coarse bilaterally throughout the rest of the lung fields. The
nurse applies a nasal cannula and administers oxygen at 2 liters per minute. When applying a
nasal cannula in the ED, which action is most important for the nurse to implement to ensure
client safety?
a) Ensure the bed is in low position and the call light is within reach
b) Determine that all electrical equipment in the room is functioning correctly and is properly
grounded
c) Use aseptic technique to prevent contamination when applying the cannula
d) Use petroleum gel on the cannula prongs to prevent irritating the nostrils - correct answer
Determine that all electrical equipment in the room is functioning correctly and is properly
grounded
Which nursing diagnosis is most relevant to James' current status?
a) Excess fluid volume
b) Inability to sustain spontaneous breathing
c) Impaired gas exchange
d) Decreased cardiac output - correct answer Impaired gas exchange
Which assessment finding further supports diagnosis?
a) Restlessness and fatigue
b) Skin is warm and flushed
c) Complaints of being thirsty
d) Blood pressure is 102/62 mmHg - correct answer Restlessness and fatigue
After determining the priority nursing diagnoses, what step should the nurse take next in
developing the plan of care?
a) Determine the need for client teaching
b) Reassess James for any changes
c) Implement the priority nursing actions
, d) Establish goals and expected outcomes - correct answer Establish goals and expected
outcomes
Which outcome statement should the nurse use for James' plan of care?
a) James will receive oxygen at 2 L/minute per nasal cannula
b) James' oxygen saturation will be monitored continuously
c) James' oxygen saturation will be greater than 95% on room air
d) The client's respiratory function will be stable - correct answer James' oxygen saturation will
be greater than 95% on room air
To achieve the desired outcome, the nurse has initiated the prescribed oxygen therapy. After
applying the nasal cannula, the nurse plans to attach a disposable sensor pad to measure the
oxygen saturation continuously. What action should the nurse implement prior to applying the
sensor?
a) Determine if James has a latex allergy
b) Clean the site with an iodine soultion
c) "Milk" the capillary blood flow of the site
d) Apply gauze padding to protect the skin - correct answer Determine if James has a latex
allergy
After receiving oxygen for a short while, James is much less dyspneic. The nurse notes that the
oxygen saturation reading is 97%. Fifteen minutes later, the oxygen saturation alarm indicates
that the reading has changed to 80%. What immediate actions should the nurse implement?
(Select all that apply).
a) Reposition the finger clip and obtain another reading
b) Assess James for signs and symptoms of respiratory distress
c) Encourage James to begin coughing and deep breathing
d) Increase the oxygen flow to 3 to 4 L/min
e) Notify the HCP immediately - correct answer -Reposition the finger clip and obtain another
reading
-Assess James for signs and symptoms of respiratory distress
-Encourage James to begin coughing and deep breathing
After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%.
Despite the normal reading, James' mother appears worried and nervous and states, "James
Mobility, Skin Integrity Hesi Case Study, HESI: Perioperative Care, HESI
Case Study: Pain, fluid balance- HESI case study, Altered Nutrition -
HESI Case Study, Constipation HESI case study
The nurse assesses James' vital signs. His respirations are rapid and shallow. Which is the best
technique for the nurse to use to assess James' respirations accurately?
a) Observe chest expansion for 15 seconds and multiply by 4
b) Encourage James to breathe as deeply and slowly as possible
c) Watch for nasal flaring and count the air exchanges with each movement
d) Place a hand on James' upper abdomen and observe the rise and fall of the chest - correct
answer Place a hand on James' upper abdomen and observe the rise and fall of the chest
James' respiratory rate is 36 breaths/minute. How should the nurse describe James' respiratory
pattern?
a) Eupnea
b) Bradypnea
c) Tachypnea
d) Orthopnea - correct answer Tachypnea
Because of James' dyspnea, the nurse is concerned that he may need to receive oxygen. To
determine the need for supplemental oxygen, which assessment is most important for the
nurse to perform?
a) Measure oxygen saturation
b) Auscultate breath sounds
c) Measure capillary refill
d) Observe chest excursion - correct answer Measure oxygen saturation
In assessing James' breath sounds, the nurse should ask him to perform which action?
a) Hold his breath for fifteen seconds
b) Observe the color of the nailbeds and lips
c) Cough deeply after each breath
d) Breathe deeply through the mouth - correct answer Breathe deeply through the mouth
,To measure capillary refill, the nurse must first perform which action?
a) Count the radial pulse rate
b) Compress the nailbed of one finger until it blanches
c) Obtain a healthcare provider's prescription
d) Elevate the extremity to be assessed - correct answer Compress the nailbed of one finger
until it blances
James' mother states that this is the third time in recent months she had brought him to the ED
with a cough and shortness of breath. The nurse asks the mother how many respiratory or
other infections James has had within the past year. Why does the nurse ask this?
a) To assess for suspected child neglect or abuse
b) To explore the possibility of antibiotic resistance developing
c) To assess for a possible immune deficiency disorder
d) To explore the need for a primary care provider to avoid ED visits - correct answer To assess
for a possible immune deficiency disorder
The nurse plans to measure James' oxygen saturation with a spring-tension finger clip. While
the nurse is explaining this procedure, James asks if it will hurt. Which response is best for the
nurse to provide?
a) "Yes, but the pain will only last a very short time."
b) "No, you will not even know the clip in on your finger."
c) "The clip feels like squeezing your finger with your other hand."
d) "You seem to be worried about experiencing pain." - correct answer "The clip feels like
squeezing your finger with your other hand."
The nurse measures James' oxygen saturation at 88% and capillary refill at 1 second. Breath
sounds are absent in the bases and coarse bilaterally throughout the rest of the lung fields. The
nurse applies a nasal cannula and administers oxygen at 2 liters per minute. Which is the most
important approach for the nurse to use when applying a nasal cannula?
a) Ensure the cannula tubing stays snugly around the ears and under the chin
b) Check that the openings in the nasal prongs are aimed into the nose to prevent skin
breakdown
c) Never allow the humidifier to run out of water
,d) Keep some type of padding around the ears and over the cheekbones - correct answer
Check that the openings in the nasal prongs are aimed into the nose to prevent skin
breakdown.
The nurse measures James' oxygen saturation at 88% and capillary refill at 1 second. Breath
sounds are absent in the bases and coarse bilaterally throughout the rest of the lung fields. The
nurse applies a nasal cannula and administers oxygen at 2 liters per minute. When applying a
nasal cannula in the ED, which action is most important for the nurse to implement to ensure
client safety?
a) Ensure the bed is in low position and the call light is within reach
b) Determine that all electrical equipment in the room is functioning correctly and is properly
grounded
c) Use aseptic technique to prevent contamination when applying the cannula
d) Use petroleum gel on the cannula prongs to prevent irritating the nostrils - correct answer
Determine that all electrical equipment in the room is functioning correctly and is properly
grounded
Which nursing diagnosis is most relevant to James' current status?
a) Excess fluid volume
b) Inability to sustain spontaneous breathing
c) Impaired gas exchange
d) Decreased cardiac output - correct answer Impaired gas exchange
Which assessment finding further supports diagnosis?
a) Restlessness and fatigue
b) Skin is warm and flushed
c) Complaints of being thirsty
d) Blood pressure is 102/62 mmHg - correct answer Restlessness and fatigue
After determining the priority nursing diagnoses, what step should the nurse take next in
developing the plan of care?
a) Determine the need for client teaching
b) Reassess James for any changes
c) Implement the priority nursing actions
, d) Establish goals and expected outcomes - correct answer Establish goals and expected
outcomes
Which outcome statement should the nurse use for James' plan of care?
a) James will receive oxygen at 2 L/minute per nasal cannula
b) James' oxygen saturation will be monitored continuously
c) James' oxygen saturation will be greater than 95% on room air
d) The client's respiratory function will be stable - correct answer James' oxygen saturation will
be greater than 95% on room air
To achieve the desired outcome, the nurse has initiated the prescribed oxygen therapy. After
applying the nasal cannula, the nurse plans to attach a disposable sensor pad to measure the
oxygen saturation continuously. What action should the nurse implement prior to applying the
sensor?
a) Determine if James has a latex allergy
b) Clean the site with an iodine soultion
c) "Milk" the capillary blood flow of the site
d) Apply gauze padding to protect the skin - correct answer Determine if James has a latex
allergy
After receiving oxygen for a short while, James is much less dyspneic. The nurse notes that the
oxygen saturation reading is 97%. Fifteen minutes later, the oxygen saturation alarm indicates
that the reading has changed to 80%. What immediate actions should the nurse implement?
(Select all that apply).
a) Reposition the finger clip and obtain another reading
b) Assess James for signs and symptoms of respiratory distress
c) Encourage James to begin coughing and deep breathing
d) Increase the oxygen flow to 3 to 4 L/min
e) Notify the HCP immediately - correct answer -Reposition the finger clip and obtain another
reading
-Assess James for signs and symptoms of respiratory distress
-Encourage James to begin coughing and deep breathing
After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%.
Despite the normal reading, James' mother appears worried and nervous and states, "James
