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 D

Explanation

A. A pulse of 60 is low but does not necessarily indicate a need to stop suctioning if the patient remains stable otherwise.
B. A pulse of 90 is within normal limits and does not require stopping suctioning.
C. An oxygen saturation of 92% is slightly low but still acceptable; suctioning can continue if the client is stable.
D. An oxygen saturation of 89% is below the acceptable threshold and indicates hypoxia, prompting the nurse to stop suctioning immediately to avoid further compromising the client's respiratory status.
E. A blood pressure of 130/80 is within normal limits and does not warrant cessation of suctioning.

A. S1 and S2 heard with diaphragm of stethoscope B. A blowing sound heard over the mitral area with the bell of the stethoscope C. Apical pulse palpated at 5th intercostal space, midclavicular line D. Absent sound over carotid arteries with bell of the stethoscope

Correct Answer is B

Explanation

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

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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?

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Naxlex Comprehensive Predictor Exams

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