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PN COPD / Exam / 100% Correct Answers

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Daniel Fuselier, a 71-year-old male, comes to the Emergency Department (ED) with a 7-day history of increased sputum production, a change in the character of sputum, increased shortness of breath, and... a fever of 101° F. He has a smoking history of two packs a day for the past 40 years, and he smoked one pack a day prior to that, beginning at the age of 14. He reports that he thinks he had asthma as a child. He has been treated with albuterol sulfate inhalers from time to time as an adult. Mr. Fuselier has been hospitalized twice with pneumonia, most recently 2 years ago. - ANS -Physical Exam After Mr. Fuselier has a physical exam in the ED, he is stabilized and admitted to a respiratory unit in the hospital with a diagnosis of pneumonia and chronic obstructive pulmonary disease (COPD). The registered nurse (RN) on the unit admits Mr. Fuselier. The practical nurse (PN) working in the unit is assigned to take care of Mr. Fuselier. The PN introduces herself to the client and asks how he would like to be addressed. The client says, "Call me Dan." The PN proceeds to obtain data. Vital signs: T 101° F, P 115, R 35, BP 120/80.Respirations rapid, shallow, and labored, with use of respiratory accessory muscles. Increased anteroposterior diameter of the chest. Skin dry and warm to touch, with poor skin turgor. Fingernail clubbing present. - ANS - 1. Which data should the PN collect next? - ANS -Auscultate breath sounds 2. The PN recognizes that which finding supports Dan's diagnosis of pneumonia? - ANS -Pulse rate of 115 The PN auscultates crackles bilaterally in the lower posterior lung fields with diminished breath sounds noted throughout all lung fields. - ANS - Arterial Blood Gas (ABG) The results of Dan's ABG analysis are as follows: pH is 7.28. pCO2 is 55. HCO3 is 25. pO2 is 89. 3. Based on these ABG results, the PN recognizes that the client is experiencing which acid-base imbalance? - ANS -Respiratory acidosis Nursing Diagnoses While reviewing the client's care plan, the PN notes the nursing diagnosis and agrees with the RN's priority nursing diagnosis. 4. When the PN is helping plan care for Dan, which nursing diagnosis has the highest priority? - ANS -Ineffective airway clearance [Show More]

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