A client with pneumonia is admitted to the medical/surgical floor. Which activity is most important for the nurse to include in the plan of care?
Administer oxygen as ordered
Allow client to choose when to eat meals
Do not allow family to visit
Ensure client gets at least 8 hours of sleep
Place client farther from the nurse's station
The Correct Answer is A
A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.
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Correct Answer is C
Explanation
A. Curved prongs fitting the nasal passages correctly is appropriate practice for comfort and effective delivery.
B. Padding pressure areas on the skin is a best practice to prevent skin breakdown and is indicative of proper care.
C. An oxygen flow rate of 10 L/min is excessively high for a nasal cannula, which typically accommodates 1-6 L/min; this indicates a need for further education on proper flow rates.
D. Posting clear no smoking and no open flame signs is essential for safety in oxygen therapy, reflecting good practice.
E. Proper adjustment of cannula tubing under the neck is necessary to ensure a secure fit without causing discomfort.
Correct Answer is C
Explanation
A. The closure of the pulmonic and mitral valves corresponds to heart sound S1, not S2.
B. The tricuspid and mitral valves close with S1.
C. Heart sound S2 represents the closure of the aortic and pulmonic valves, signaling the end of systole and the beginning of diastole.
D. The mitral valve closes with S1, not S2.
E. The pulmonic and tricuspid valves do not correspond with S2.