Community Health HESI

Correct Answer: D

Rationale: In a client with COPD admitted with pneumonia, a productive cough with green sputum indicates a potential bacterial infection. Green sputum is commonly associated with bacterial pneumonia, which requires immediate intervention with appropriate antibiotics. Monitoring oxygen saturation, respiratory rate, and heart rate are essential in COPD patients, but the presence of green sputum suggests an urgent need for targeted treatment to address the underlying infection. Oxygen saturation of 88% is concerning but may not directly indicate the need for immediate intervention in the absence of other critical symptoms. Respiratory rate of 24 breaths per minute and a heart rate of 90 beats per minute are within normal limits and may not be indicative of an acute issue requiring immediate intervention in this context.

Correct Answer: B

Rationale: Reviewing the client's current medication regimen helps identify any potential issues and ensures that the client is taking the correct medications.

Correct Answer: A

Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.

Correct Answer: B

Rationale: Hepatitis A is often spread through close personal contact and poor sanitary conditions, which are more common in low-income, cramped living situations.

Correct Answer: D

Rationale: Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear) are signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a halo sign with CSF leakage from the ears or nose.