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RN Adult Medical Surgical Online Practice 2023-2024 B: Questions & Answers, Exams of Nursing

A series of multiple-choice questions and answers related to adult medical-surgical nursing. It covers various topics, including neurological deficits, bacterial meningitis, post-gastrectomy care, migraine headaches, rattlesnake bites, traumatic brain injury, magnesium sulfate administration, compartment syndrome, diabetes insipidus, peripheral arterial disease, pernicious anemia, transurethral resection of the prostate (turp), cholecystitis, hyperthyroidism, total parenteral nutrition (tpn), pneumothorax, methicillin-resistant staphylococcus aureus (mrsa), pressure injuries, and dementia. Designed to help nurses prepare for clinical practice and exams.

Typology: Exams

2024/2025

Available from 11/10/2024

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RN Adult Medical Surgical Online Practice 2023-

2024 B. Questions and Correct Verified Answers.

Graded A

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? - ANSExpressive aphasia is incorrect. Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a left-hemispheric stroke.Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke.Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke.Right hemiplegia is incorrect. Right hemiplegia occurs secondary to a left-hemispheric stroke.One-sided neglect is correct. One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? - ANSWear a mask.

Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy. Wear a gown. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy. Medical History Since discharge, client reports several episodes of dizziness, "fast" heartbeat, and abdominal cramping. Client states, "I am afraid to eat." A nurse is providing teaching for the client. Which of the following instructions should the nurse include? Select all that apply. - ANSMaintain a high carbohydrate intake is incorrect. Dumping syndrome requires a low carbohydrate diet because of reactive hypoglycemia. Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three servings of unsweetened cooked or canned fruit per day. Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30 min before or after meals. Eat several small meals per day is correct. The nurse should instruct the client to eat several small, frequent meals instead of three large meals per day.

Consume high-protein snacks is correct. The client should eat snacks that are high in protein and low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome. Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid excessive amounts of spices and salt. A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? - ANSNaproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding. A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? - ANSAdminister an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

A nurse in an ICY is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? - ANSBradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure. A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? - ANSRespiratory paralysis The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate. A nurse is assessing a client who had a plaster cast applied to heir left leg 2 hr ago. Which of the following actions should the nurse take? - ANSCheck that one finger fits between the cast and the leg.

To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application. A nurse is assessing a client who has diabetes insidious. Which of the following findings should the nurse expect? - ANSLow urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? - ANSHair loss on the lower legs The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth. A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition cause by pernicious anemia? - ANSThis image depicts glossitis, which

can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in a urinary output. Which of the following actions should the nurse take? - ANSIrrigate the indwelling urinary catheter. The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow. A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? - ANSPain that increases with passive movement The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight. A nurse is caring for a client in the emergency department (ED). Physical Examination

Client presents to the ED with upper abdominal pain that radiates to the right shoulder. Client rates pain as 7 on a scale of 0 to 10. Client also reports nausea, vomiting, and dyspepsia. Client is awake, alert, and oriented x3. Lung sounds clear bilaterally, S1 and S heart tones noted. All pulses palpable. Bowel sounds active in all 4 quadrants. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. - ANSThe nurse should plan to administer an opioid analgesic, such as morphine, for acute pain. Since the client is experiencing nausea and vomiting, the nurse should also ensure they are NPO. The client is likely experiencing cholecystitis, which typically presents with nausea, vomiting, upper abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The client also has elevated liver enzymes and a WBC count, which is consistent with cholecystitis. Surgical management for cholecystitis might be indicated. The nurse should monitor the client's stool and urine color because a biliary obstruction from gallstones may cause clay-colored stools and dark urine. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? - ANSBlood pressure 170/80 mm Hg

Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm. A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The pumps would be set at how many mL/hr? - ANS A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following finds is an indication of lung re-expansion? - ANSBubbling in the water seal chamber has ceased. Bubbling in the water seal chamber ceases when the lung re-expands. A nurse is caring for a client who has a positive culture for methicillin-resistant staphylococcus aureus (MRSA). Which of the following actions should the nurse take? - ANSBathe the client using chlorhexidine solution. The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

A nurse is caring for a client who has a stage 3 pressure injury. Which of the following findings contributes to delayed wound healing? - ANSUrine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. A nurse is caring for a client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraint the client? - ANSKeep the client occupied with a manual activity. The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? - ANSInstruct the client to allow the machine to breathe for them. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal

instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator." A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? - ANSDecreased viral load Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment. A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter reading have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? - ANSNonrebreather mask The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask. A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy. Nurses' Notes

2000:

Client reports pain as 3 on a scale of 0 to 10. Breath sounds clear and present throughout. Three abdominal bandages to abdomen, dry and intact with no drainage noted. Client voided 90 mL of clear-yellow urine into bedpan. Perineal pad with small amount of blood, no clots; perineal pad changed at this time. Click to highlight the findings the nurse should report to the provider immediately.

  • ANSPerineal pad saturated with blood, large clots present, blood pressure trend, and heart rate of 102/min are correct. The client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should report these findings to the provider. Client sleeping, arouses to verbal stimuli, respiratory rate 14/min, oxygen saturation 95% on room air, breath sounds clear, and reports pain as 2 on scale of 0 to 10 are incorrect. These are expected findings. Therefore, the nurse does not need to report these findings to the provider. A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? - ANSScan the bladder with a portable ultrasound. The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.

A nurse is caring for a client who is experiencing supra ventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take? - ANSPerform synchronized cardioversion. The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? - ANSInject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? - ANSStress ulcers

Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? - ANSInstruct the client on alternative therapies for pain reduction. The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction. A nurse is caring for a client who is scheduled for a right knee arthroplasty. Nurses' Notes 0600: Client is admitted for surgery this a.m. Vital signs recorded. Consents reviewed. Client reports understanding of surgery and has no further questions for provider. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching?

Select all that apply. - ANS"Well, I guess there's no changing my mind about having surgery now" is incorrect. The nurse and the client reviewed the consents; therefore, the nurse has instructed the client that they have the right to refuse surgery at any time. "I will need to do the breathing exercises every 1 to 2 hours after the surgery" is correct. The client should cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative complications, such as pneumonia. "I will be sure to ask for pain medication before my knee starts to hurt too bad" is correct. For optimal control of postoperative pain, the client should request analgesic medication before the pain becomes severe. "My physical therapy will start after I leave the hospital" is incorrect. Early ambulation leads to improved postoperative outcomes and reduces the risk of complications of immobility, such as pneumonia and atelectasis. The client should be informed that physical therapy will begin the day of, or the day following, surgery. "I will probably be going home with a walker" is correct. It can take 6 weeks for complete recovery from knee arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks following surgery. A nurse is caring for a client who was just admitted from the emergency department (ED).

Nurses' Notes 0945: Client is experiencing a sickle cell crisis. Client states that they began experiencing pain in the lower extremities 3 days ago and is now experiencing pain in the chest, rating it as 4 on scale of 0 to 10. Oxygen at 3 L/min via nasal cannula in place. Oral mucosa pink, no cyanosis. Pulses palpable in all four extremities, no peripheral edema noted. Respirations even and slightly labored; lung sounds with slight wheezing in left upper lobe. Abdomen soft and nontender, bowel sounds active in all four quadrants. 0.45% sodium chloride IV at 200 mL/hr infusing to left hand with no reports of pain or swelling at the site. Drag words from the choices below to fill in each blank in the following sentence. - ANSFluid volume overload is incorrect. While the client is experiencing an increased respiratory rate and shortness of breath, fluid volume overload typically includes moist crackles on auscultation, pitting edema in dependent areas, neck vein distension, and hypertension. Right-sided heart failure is incorrect. While clients who have sickle-cell disease are at risk for developing heart failure, the client does not have manifestations of right-sided heart failure. Right-sided heart failure typically presents with signs of

fluid volume overload, which includes jugular vein distention, dependent edema, and blood pressure alterations. Acute chest syndrome is correct. The client is most likely experiencing acute chest syndrome, which can be caused by respiratory infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome, which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain. Pneumonia is correct. The client is most likely experiencing pneumonia as evidenced by the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain. Pneumothorax is incorrect. While the client is experiencing increased respiratory distress, a pneumothorax typically presents with reduced or absent breath sounds and unequal chest expansion. A nurse is caring for a client. History and Physical Client admitted to the medical-surgical unit with severe, acute abdominal pain, abdominal distention, diarrhea, mucus and small amount of blood in the stool, and a 12% weight loss over the past 2 months. Client's weight 2 months ago was 100.3 kg (221.1 lb). Client has a history of Crohn's disease and a seizure disorder that is managed with diet and medication. The nurse has completed their performing an assessment of the client and reviewing the client's EMR.

(For each of the client's assessment finding, click to specify if the finding is consistent with appendicitis or Crohn's disease. Each finding may support more than one disease process.) - ANSWhen analyzing cues, the nurse should identify that the client's assessment findings of right lower quadrant pain, fever, and client report of anorexia indicates appendicitis. When analyzing cues, the nurse should identify that the client's assessment findings of blood in stool, right lower quadrant pain, fever, and client report of anorexia indicates Crohn's disease. A nurse is caring for a client. Laboratory Results Day 10700: Hgb 12 g/dL (12 to 168 g/dL female) Hct 34% (37% to 4752% female) WBC count 19,000/mm³ (5,000 to 10,000/mm³) Neutrophils 75% (55% to 70%) Erythrocyte sedimentation rate (ESR) 18 mm/hr (less than 15 mm/hr) Complete the following sentence by using the lists of options. - ANSWhen prioritizing hypotheses and using the priority framework of urgent vs non-urgent approach to client care, the nurse first should address the client's abdominal findings followed by the client's pain rating. Abdominal distention is a manifestation of an inflammatory intestinal disorder. The nurse should address

this finding first to reduce the risk of life-threatening complications, such as obstruction or infection. The nurse should next address the client's pain rate of 8 which indicates moderate pain which requires intervention by the nurse. A nurse is caring for a client. Nurses' Notes 1200: Client was admitted to the unit with shortness of breath, a nonproductive cough, chest discomfort, and myalgia. Prefers orthopneic position. Client reports that manifestations began about 2 days ago. For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process. - ANSTemperature is consistent with pneumonia. Fever is a manifestation of pneumonia and is related to inflammation or infection. Breath sounds are consistent with emphysema, asthma, and pneumonia. The client's wheezing is a manifestation of emphysema, asthma, and pneumonia. It is the result of narrowed airways and alveoli. ABG results are consistent with emphysema and pneumonia. The client's ABG results indicate respiratory acidosis, which is a manifestation of emphysema and pneumonia.

Respiratory rate is consistent with emphysema, asthma, and pneumonia. The client's respiratory rate is a manifestation of emphysema, asthma, and pneumonia. Heart rate is consistent with emphysema and pneumonia. The client is experiencing tachycardia, which is a manifestation of emphysema and pneumonia. Cough is consistent with emphysema, asthma, and pneumonia. The client's cough is a manifestation of emphysema, asthma, and pneumonia. A nurse is caring for a client. Nurses' Notes Day 1 1000: Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache." Client is alert and oriented to person, place, and time. A nurse is prioritizing client care. Complete the following sentence by using the lists of options. - ANSDropdown 1 Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to address the client's

oxygen saturation. The client's oxygen saturation is 88%, which indicates hypoxemia and requires supplemental oxygen. Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is a manifestation of an infection. However, there is another finding the nurse should address first. BUN level is incorrect. The nurse should address the client's BUN level because it is elevated. However, there is another finding the nurse should address first. Dropdown 2 Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can result in decreased cardiac output. However, there is another finding the nurse should address first. Temperature is correct. The nurse should next address the client's elevated temperature, which is a manifestation of an infection. The client's elevated temperature can cause an increase in other vital signs, such as heart rate. Headache is incorrect. The nurse should address the client's headache, which is a manifestation of an infection. However, there is another finding the nurse should address first. A nurse is caring for a client. Nurses' Notes Day 1

1000:

Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache." Client is alert and oriented to person, place, and time. The nurse is planning care for the client. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. - ANSCough and deep breathe every 2 hr is anticipated. The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange. Obtain a sputum culture and sensitivity is anticipated. The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed. Perform neurological checks every 2 hr is nonessential. The client is alert and oriented to person, place, and time. Therefore, the nurse does not need to perform neurological checks every 2 hr. Administer oxygen at 3 L/min via nasal cannula is anticipated. The client's oxygen saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer oxygen at 3 L/min via nasal cannula. Limit the client's fluid intake to 1,500 mL per day is contraindicated. The client has manifestations of dehydration. Therefore, fluid restriction is contraindicated.

Acetaminophen 500 mg PO every 6 hr as needed is anticipated. The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature and promote comfort. Famotidine 40 mg PO daily is nonessential. Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily. A nurse is caring for a client. Nurses' Notes Day 1 1000: Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache." Client is alert and oriented to person, place, and time. The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply. - ANSPCO2 level is correct. The client has an elevated PCO2 level, which indicates the retention of carbon dioxide. Therefore, this finding requires follow-up by the nurse. WBC count is correct. The client has an elevated WBC count, which indicates an infection. Therefore, this finding requires follow-up by the nurse.

Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Calcium level is incorrect. The client's calcium level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. HCO3- level is incorrect. The client's HCO3- level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or kidney disease. Therefore, this finding requires follow-up by the nurse. A nurse is caring for a client. Nurses' Notes Day 1 1000: Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache." Client is alert and oriented to person, place, and time.

The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again. - ANSHeart rate is 72/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Respiratory rate is 20/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Blood pressure is 128/56 mm Hg is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Oxygen saturation is 95% on room air is correct. The client's oxygen saturation is within the expected reference range and no longer requires supplemental oxygen. Therefore, this finding indicates the client's pulmonary status is improving. Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon auscultation is incorrect. The nurse should identify that the client's lungs sounds are still diminished in the bilateral posterior bases with occasional crackles heard upon auscultation due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving.

Cough is productive with yellow mucus is incorrect. The client's cough is still productive with yellow mucus due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving. A nurse is caring for a client. Nurses' Notes Day 1 1000: Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache." Client is alert and oriented to person, place, and time. The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. - ANSClient is short of breath and has a productive cough with yellow mucus is correct. Shortness of breath, along with a productive cough with yellow mucus, indicates a potential problem. "I could barely breathe when I got up this morning and I had a throbbing headache" is correct. Difficulty breathing and a throbbing headache indicates a potential problem.