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 C

Explanation

A. Covert: Covert data refers to information that is hidden, subjective, or not immediately observable, such as symptoms reported by the client. Voided volume is measurable and observable, so it is not covert.

B. Subjective: Subjective data is information reported by the client, such as feelings, perceptions, or symptoms. Since the urine output is a measurable and observable fact, it is not subjective.

C. Objective: Objective data is factual, measurable, and observable. The voided volume of 475 ml is a precise, quantifiable measurement, making it objective data.

D. Symptomatic: Symptomatic data pertains to symptoms experienced by the client, which are typically subjective. The documented urine output is a specific, quantifiable measurement and not a symptom.

A. Increased subcutaneous fat B. Increased skin turgor and moisture C. Decreased bone density D. The skin is more elastic E. Muscle mass gradually decreases F. Decreased auditory acuity

Correct Answer is ["A","C","E","F"]

Explanation

A. Increased subcutaneous fat: Middle adulthood often sees an increase in fat deposits, particularly around the abdomen, due to changes in metabolism and hormonal shifts.

B. Increased skin turgor and moisture: Incorrect. Aging typically leads to decreased skin turgor and moisture, causing the skin to become drier and less elastic.

C. Decreased bone density: Bone density generally decreases due to reduced bone remodeling, increasing the risk of fractures and osteoporosis.

D. The skin is more elastic: Incorrect. Skin elasticity usually decreases with age, resulting in wrinkles and sagging.

E. Muscle mass gradually decreases: Muscle mass tends to decline with age, a condition known as sarcopenia, leading to reduced strength and physical capability.

F. Decreased auditory acuity: Hearing loss, particularly high-frequency hearing loss, is common as people age due to changes in the inner ear and other auditory structures

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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

At the end of the shift, the nurse documents that the client has voided 475 ml during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Correct Answer is C

Explanation

Which of the following are physical changes that occur in middle adulthood? Select all that apply.

Correct Answer is ["A","C","E","F"]

Explanation

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