The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Document "impaired oxygenation" on the nursing care plan.

Auscultate the chest for breath sounds.

Collaborate with the client to form goals.

Apply supplemental oxygen by face mask as needed.

Answer and Explanation

The Correct Answer is B

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

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Correct Answer is B

Explanation

A. Concrete operational: This stage (7 to 11 years) is characterized by logical thinking about concrete events.

B. Sensorimotor: This stage (birth to about 2 years) is when infants learn about the world through their senses and actions. Object permanence—the understanding that objects continue to exist even when they cannot be seen, heard, or touched—develops in this stage.

C. Formal operational: This stage (12 years and up) involves abstract and moral reasoning.

D. Preoperational: This stage (2 to 7 years) is when children begin to engage in symbolic play and learn to manipulate symbols, but they don’t yet understand concrete logic.

A. "I will begin 48 hr before the client's discharge." B. "I will begin once the client's insurance company approves discharge coverage." C. "I will begin once the client's discharge order is written." D. "I will begin upon the client's admission to the facility."

Correct Answer is D

Explanation

A. "I will begin 48 hr before the client's discharge." Waiting until 48 hours before discharge does not provide enough time for thorough planning, education, or addressing potential needs after discharge.

B. "I will begin once the client's insurance company approves discharge coverage." Discharge planning should not depend solely on insurance approval. It needs to be proactive and begin earlier to ensure comprehensive planning and education.

C. "I will begin once the client's discharge order is written." Starting discharge planning only after the discharge order is written does not allow adequate time for preparation and may result in rushed or incomplete planning.

D. "I will begin upon the client's admission to the facility."Discharge planning should start at admission. Early planning ensures that all aspects of post-discharge care are considered and allows ample time for education, coordination, and addressing potential barriers to successful discharge.

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The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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