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 D

Explanation

Choice A reason:

Initiating droplet precautions is not sufficient for a client presenting with symptoms such as coughing up blood, productive cough, and night sweats. These symptoms are indicative of possible tuberculosis (TB), which is an airborne disease. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza or pertussis, but not for TB.

Choice B reason:

Considering standard precautions to be sufficient is incorrect. Standard precautions are the basic level of infection control that should be used in the care of all patients to prevent the spread of infections. However, for a client with symptoms suggestive of TB, additional airborne precautions are necessary to prevent the spread of the disease.

Choice C reason:

Transferring the client to a positive pressure room is inappropriate. Positive pressure rooms are designed to keep contaminants out and are used for protecting immunocompromised patients from infections. For a client with suspected TB, a negative pressure room is required to prevent the spread of infectious particles to other areas.

Choice D reason:

Initiating airborne precautions is the correct intervention. Airborne precautions are necessary for diseases that are transmitted through smaller respiratory droplets that can remain suspended in the air and be inhaled by others. Tuberculosis is one such disease, and initiating airborne precautions helps to prevent the spread of the infection to healthcare workers and other patients.

A. Hold breath for 5 seconds and exhale / shake inhaler. B. Place mouthpiece in mouth / exhale slowly and completely. C. Press and hold the canister down while inhaling deeply and slowly / exhale slowly and completely. D. Remove cap from inhaler and shake inhaler / rinse your mouth, gargle, spit out.

Correct Answer is D

Explanation

Choice A reason:

Holding your breath for 5 seconds and exhaling is not the first step in using an MDI. Shaking the inhaler is necessary to ensure the medication is properly mixed, but it should be done after removing the cap.

Choice B reason:

Placing the mouthpiece in the mouth and exhaling slowly and completely is an important step, but it is not the first priority. Exhaling fully before inhaling the medication helps ensure that the medication reaches deep into the lungs.

Choice C reason:

Pressing and holding the canister down while inhaling deeply and slowly is a crucial step in using an MDI, but it is not the first step. This action releases the medication into the lungs.

Choice D reason:

Removing the cap from the inhaler and shaking it is the first priority step. This ensures the medication is ready for use. Rinsing your mouth, gargling, and spitting out after using the inhaler is the last priority step to prevent oral thrush and other side effects.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newly admitted client whose chief complaint is “coughing up blood” and whose recent history includes a productive cough and night sweats. What is the nurse’s priority intervention?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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