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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "I will make exercise a part of my daily activities." This is a positive and correct statement. Regular exercise is an important component of a healthy lifestyle and should be encouraged.

B. "I should eat a diet high in fats but low in fiber." This statement is incorrect and indicates a misunderstanding of healthy dietary guidelines. A diet high in fats and low in fiber is not recommended for maintaining health and can lead to various health issues like obesity, heart disease, and digestive problems.

C. "I only have one glass of wine a day with dinner." This statement aligns with moderate alcohol consumption guidelines, which suggest that up to one glass of wine per day for women and two for men can be part of a healthy lifestyle.

D. "I will begin a smoking cessation program this week." This statement reflects a positive health choice. Quitting smoking is one of the most beneficial actions a person can take for their health, reducing risks for many diseases.

A. Emergency B. Time-lapse C. Focused D. Initial

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.

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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?

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