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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Has both older and younger siblings: This does not specifically relate to the "sandwich generation" concept.
B. Cares for children and aging parents at the same time: The term "sandwich generation" refers to individuals who are simultaneously caring for their own children and their aging parents.
C. There is a role reversal between parents and self: While this may occur in caregiving situations, it doesn't define the "sandwich generation."
D. Assists own parents and spouse's parents: This is similar to option B but specifically refers to assisting one's own parents and the spouse's parents, not necessarily at the same time.
Correct Answer is A,B,C,D,E
Explanation
Trust vs. Mistrust (Birth to 1 year): In this stage, infants learn to trust or mistrust their caregivers and the world based on the consistency of care they receive.
Autonomy vs. Shame and Doubt (1 to 3 years): During this stage, toddlers learn to exercise will and to do things independently; failure to do so causes shame and doubt.
Initiative vs. Guilt (3 to 6 years): In this stage, children begin to assert control and power over their environment through directing play and other social interactions.
Industry vs. Inferiority (6 to 12 years): Here, children learn to read, write, and do things on their own. Peers and teachers become significant figures, and children strive to be competent and successful.
Identity vs. Role Confusion (12 to 18 years): Adolescents search for a sense of self and personal identity, through an intense exploration of personal values, beliefs, and goals.
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