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    HESI Compass exit proctored exam

    A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include a heart rate of 122 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 170/90 mm Hg. Which assessment finding warrants the most immediate intervention by the nurse?

    Explanation & Rationale

    Choice A reason: Yellow expectorated sputum is indicative of an infection but does not require immediate intervention.Choice B reason: An oral temperature of 100.5°F (38.1°C) suggests a mild fever, common with infections and manageable with antipyretics.Choice C reason: Bilateral diffuse wheezing is a sign of airway obstruction and requires immediate intervention to ensure the client's airway remains open and they are able to breathe effectively.Choice D reason: Shortness of breath on exertion is expected in clients with COPD and pneumonia but does not require the most immediate intervention compared to wheezing.

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