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 A
Explanation
A. Emergency: This type of assessment is rapid and focuses on identifying and treating life-threatening conditions immediately, such as profuse bleeding from a stab wound.
B. Time-lapse: This assessment compares current client data to previous data to assess progress, which is not appropriate for an acute, life-threatening situation.
C. Focused: While this is a detailed assessment of a specific problem area, an emergency assessment is needed first for immediate threats to life.
D. Initial: This is a comprehensive assessment typically conducted when a client first enters a healthcare setting, but in an emergency, the focus shifts to immediate life-saving measures.
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.
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