A client with pneumonia is admitted to the medical/surgical floor. Which activity is most important for the nurse to include in the plan of care?

Administer oxygen as ordered

Allow client to choose when to eat meals

Do not allow family to visit

Ensure client gets at least 8 hours of sleep

Place client farther from the nurse's station

Answer and Explanation

The Correct Answer is A

A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.

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Correct Answer is C

Explanation

A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.

A. Music B. Aromatherapy C. Heat application D. Distraction E. Guided Imagery

Correct Answer is E

Explanation

A. Music can be a soothing nonpharmacologic method to reduce pain and may help with relaxation, even for confused patients, as it typically doesn’t require cognitive engagement.
B. Aromatherapy is generally safe and may offer calming effects for older adults without relying heavily on cognitive processing.
C. Heat application is a physical pain relief method, and as long as safety precautions are taken, it can be used effectively in confused patients.
D. Distraction can be a beneficial technique for pain relief and is often effective without requiring cognitive engagement.
E. Guided Imagery should be avoided in confused older adults, as it relies on the patient's ability to follow instructions and visualize mental images, which can be challenging and potentially frustrating for someone with cognitive impairment.

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A client with pneumonia is admitted to the medical/surgical floor. Which activity is most important for the nurse to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

Correct Answer is C

Explanation

Which nonpharmacologic pain treatment should the nurse avoid using in an older adult who shows signs of confusion?

Correct Answer is E

Explanation

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