Community Health HESI

Correct Answer: C

Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.

Correct Answer: C

Rationale: Gradually tapering the dose over one to two weeks should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias.

Correct Answer: C

Rationale: Jugular vein distention indicates increased central venous pressure, which requires immediate intervention in a client with pneumonia.

Correct Answer: C

Rationale: Administering the medication with a small amount of pudding helps prevent aspiration in clients with dysphagia.

Correct Answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.