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. CVA tenderness is associated with renal issues, not directly with congestive heart failure.
B. A CVA angle of 160 degrees is abnormal; a normal angle is closer to 90 degrees, indicating potential issues.
C. A greater CVA angle can be observed in patients with kyphosis, where the spine curves excessively, affecting rib positioning.
D. A pneumothorax typically results in reduced breath sounds and tracheal deviation, not specifically linked to CVA angle changes.
E. A barrel chest results in an increased AP diameter, not typically associated with CVA angle changes.
Correct Answer is C
Explanation
A. Supine is not recommended, as it can make breathing more difficult by limiting chest expansion.
B. Trendelenberg is not suitable for someone with breathing difficulties, as this position can worsen dyspnea.
C. High-Fowler is the best position for an asthma patient experiencing shortness of breath as it promotes lung expansion and allows for maximum chest wall movement.
D. Semi-Fowler may help but is less effective than High-Fowler in cases of acute respiratory distress.
E. Left-lateral does not optimize chest expansion and is not typically recommended for respiratory distress.