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. "Do you smoke?" This is a closed-ended question that can be answered with a simple "yes" or "no." It doesn't encourage elaboration or detailed responses.

B. "How are you feeling?" This is an open-ended question that encourages the client to provide more detailed and descriptive responses about their current state or feelings. It allows the client to share more information and gives the nurse a better understanding of their condition.

C. "Are you feeling well?" Similar to option A, this is a closed-ended question. It prompts a "yes" or "no" answer without inviting further discussion or detailed explanation.

D. "Do you use any illicit drugs?" This is another closed-ended question that requires a "yes" or "no" answer. It does not provide the opportunity for the client to discuss their drug use in detail.

A. Ongoing assessment B. Focused assessment C. Emergency assessment D. Comprehensive assessment

Correct Answer is A

Explanation

A. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

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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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Correct Answer is A

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