A client with left lower lobe pneumonia has activity intolerance related to impaired oxygen supply and demand as evidenced by fatigue, dyspnea, and difficulty performing self-care. Which expected outcome must be included in the care plan related to this problem? The client will:

Have a pulse oximetry reading of 95% or greater by discharge.

Exhibit a respiratory rate of 12-20/minute by discharge.

Perform self-care activity without dyspnea by discharge.

Have clear breath sounds bilaterally by discharge.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Have a pulse oximetry reading of 95% or greater by discharge: While maintaining a pulse oximetry reading of 95% or greater is important, it may not fully address the client’s activity intolerance. Pulse oximetry measures the oxygen saturation in the blood, and normal readings typically range from 95% to 100%. However, achieving this reading alone does not ensure that the client can perform activities without experiencing dyspnea or fatigue.

Choice B reason:

Exhibit a respiratory rate of 12-20/minute by discharge: A normal respiratory rate for adults is between 12 and 20 breaths per minute. While this is a good indicator of respiratory function, it does not directly address the client’s ability to perform self-care activities without dyspnea. The goal should focus on the client’s functional ability rather than just physiological parameters.

Choice C reason:

Perform self-care activity without dyspnea by discharge: This outcome directly addresses the client’s activity intolerance. Dyspnea, or difficulty breathing, is a significant symptom that affects the client’s ability to perform daily activities. By setting a goal for the client to perform self-care activities without dyspnea, the care plan focuses on improving the client’s functional status and quality of life.

Choice D reason:

Have clear breath sounds bilaterally by discharge: Clear breath sounds are an important indicator of improved lung function and resolution of pneumonia. However, this outcome does not specifically address the client’s activity intolerance. While clear breath sounds are desirable, the primary goal should be to ensure the client can perform activities without experiencing dyspnea.

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Correct Answer is B

Explanation

Choice A reason:

Pulse oximetry is 90% is not an ideal indicator of effective treatment. A normal pulse oximetry reading is typically between 95% and 100%. A reading of 90% suggests that the patient may still be experiencing hypoxemia, which indicates that the pneumonia may not be fully resolved.

Choice B reason:

White blood cell count is 9000/µL is a strong indicator that the treatment has been effective. A normal white blood cell (WBC) count ranges from 4,000 to 11,000/µL. An elevated WBC count is often seen in infections, and a return to normal levels suggests that the infection is resolving.

Choice C reason:

Bronchial breath sounds heard at the right base are not typically a sign of improvement. These sounds can indicate consolidation or fluid in the lungs, which are common in pneumonia. Effective treatment should result in the reduction of abnormal breath sounds.

Choice D reason:

Sputum that is light yellow in color does not necessarily indicate effective treatment. While a change in sputum color can be a sign of improvement, it is not as reliable as other clinical indicators such as WBC count or improvement in symptoms

A. Covers the mouth and nose when coughing. B. Reports daily to the public health department. C. Demonstrates correct use of the N95 mask. D. Washes dishes and personal items after use.

Correct Answer is A

Explanation

Choice A reason: Covering the mouth and nose when coughing is a critical measure to prevent the spread of tuberculosis (TB). TB is primarily transmitted through airborne particles when an infected person coughs, sneezes, or talks. By covering the mouth and nose, the client reduces the risk of spreading the bacteria to others, which is a fundamental goal of TB transmission education.

Choice B reason: Reporting daily to the public health department is important for monitoring and managing TB treatment, but it does not directly relate to preventing the transmission of TB. This action is more about ensuring adherence to treatment protocols and monitoring the client’s health status.

Choice C reason: Demonstrating correct use of the N95 mask is also crucial in preventing the spread of TB, especially in healthcare settings or when the client is in close contact with others. The N95 mask filters out airborne particles, including TB bacteria, thereby reducing the risk of transmission. However, this measure is typically emphasized in specific situations rather than as a general practice for all clients with TB.

Choice D reason: Washing dishes and personal items after use is good hygiene practice but is not specifically related to the transmission of TB. TB is not spread through contact with dishes or personal items but through airborne particles.

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A client with left lower lobe pneumonia has activity intolerance related to impaired oxygen supply and demand as evidenced by fatigue, dyspnea, and difficulty performing self-care. Which expected outcome must be included in the care plan related to this problem? The client will:

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Explanation

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Correct Answer is A

Explanation

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