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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 20 lbs: This is a plausible estimate. By 12 months, an infant's birth weight typically triples. Therefore, an 8 lb birth weight would approximately translate to 24 lbs at 12 months.
B. 32 lbs: This estimate is too high. If an infant's birth weight triples by 12 months, an 8 lb birth weight would not be expected to reach 32 lbs.
C. 24 lbs: An infant's weight usually triples by their first birthday. Therefore, an infant born weighing 8 lbs would be expected to weigh about 24 lbs at 12 months.
D. 16 lbs: This is an underestimate. An 8 lb infant would double their birth weight by about 4 to 6 months, and by 12 months, they would typically have tripled their birth weight to around 24 lbs.
Correct Answer is A
Explanation
A. Parallel play: Parallel play is typical of toddlers, where they play alongside each other but do not interact or play directly with each other. This is a key stage in social development where they start to notice peers but prefer independent activities.
B. Cooperative play: Cooperative play involves children playing together with a common goal or activity. This type of play is more typical of older preschoolers and school-age children.
C. Solitary play: Solitary play is common in infants and very young toddlers where they play alone and are not engaged with others. By the toddler stage, children often progress to parallel play.
D. Associative play: Associative play involves children interacting and playing together, but not with a structured goal or organization. This typically develops after parallel play, around the preschool age.
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