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 B
Explanation
A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.
Correct Answer is A
Explanation
A. In peripheral arterial insufficiency, blood flow is reduced, leading to cooler skin temperatures, especially in the affected extremity.
B. Nail appearance may be unhealthy due to poor perfusion; nails may become thickened or grow slowly.
C. Skin is typically cool and may be dry, not warm, indicating reduced blood flow.
D. A pulse of 2+ is within normal range; however, pulses may be diminished or absent in cases of significant arterial insufficiency.
E. The leg typically does not appear swollen; rather, it may show signs of atrophy or hair loss due to inadequate blood supply.