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 A

Explanation

Choice A reason:

Sitting upright is the best position for a respiratory assessment. This position allows for optimal lung expansion and makes it easier to auscultate breath sounds accurately. It also helps in observing the client’s breathing pattern and effort.

Choice B reason:

Semi-Fowler’s position, where the head of the bed is elevated to 30-45 degrees, is often used for clients with respiratory issues to promote lung expansion and reduce the risk of aspiration. However, it is not as effective as the sitting upright position for a thorough respiratory assessment.

Choice C reason:

The supine position, where the client lies flat on their back, is not ideal for a respiratory assessment. This position can limit lung expansion and make it more difficult to hear breath sounds clearly.

Choice D reason:

The side-lying position is also not suitable for a respiratory assessment. This position can cause uneven lung expansion and make it challenging to assess both lungs accurately.

A. Bronchitis B. A pneumothorax C. Asthma D. Emphysema

Correct Answer is A

Explanation

Choice A reason: Fine crackles are often associated with bronchitis, particularly chronic bronchitis. These sounds are caused by the presence of mucus in the airways, which creates a crackling noise when air passes through. Chronic bronchitis involves inflammation and increased mucus production in the bronchi, leading to these characteristic lung sounds.

Choice B reason: A pneumothorax, or collapsed lung, typically presents with absent or diminished breath sounds on the affected side rather than fine crackles. The absence of breath sounds is due to the lack of air movement in the collapsed portion of the lung. Fine crackles are not a common finding in pneumothorax.

Choice C reason: Asthma is characterized by wheezing, which is a high-pitched whistling sound caused by narrowed airways. While crackles can occasionally be heard in asthma, they are not the primary lung sound associated with this condition. Wheezing is more indicative of asthma due to bronchoconstriction and inflammation.

Choice D reason: Emphysema, a form of chronic obstructive pulmonary disease (COPD), typically presents with decreased breath sounds and prolonged expiration rather than fine crackles. The destruction of alveolar walls in emphysema leads to reduced lung sounds overall. Fine crackles are not a hallmark of emphysema.

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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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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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