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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer oxygen at 2 L/min: Administering oxygen is important but should be done after positioning the client to improve natural ventilation.
B. Raise the head of the bed: Raising the head of the bed is the first action to take as it facilitates better lung expansion and improves ventilation. This can help increase the oxygen saturation more immediately and effectively.
C. Encourage coughing and deep breathing: Encouraging coughing and deep breathing is also beneficial to help clear secretions and improve lung function, but positioning the client for optimal breathing should be prioritized first.
D. Administer prescribed analgesic medication. Administering analgesics may be necessary for pain management, but it does not directly address the immediate need to improve oxygen saturation.
Correct Answer is C
Explanation
A. Cognitive dysfunction: This is a broad term that includes various types of cognitive impairment.
B. Alzheimer's disease: This is a specific type of dementia, but it doesn’t specifically describe the timing of confusion.
C. Sundowning syndrome: This term describes increased confusion and agitation in the late afternoon and evening. It’s commonly seen in individuals with dementia.
D. Night-time confusion: This is a general term and doesn't specifically relate to the characteristic pattern of sundowning.
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