Medical Surgical Pneumonia #3

Question

The nurse is assessing a client with viral pneumonia. Which areas in the focused assessment may determine significant findings in this client? Select all that apply.

Answers

  1. Color of nail beds.
    • Rationale:

      This answer is correct because the color of a client’s nail beds can provide essential information regarding a client’s oxygenation status. This is an important part of a focused respiratory assessment for a client with pneumonia.

  2. Quality of breath sounds.
    • Rationale:

      This answer is correct because auscultation of breath sounds is a critical aspect of a focused respiratory assessment for a client with pneumonia. Breath sounds should be auscultated at least every 2 hours in order to monitor for improvement or deterioration of the client’s condition.

  3. Chest pain.
    • Rationale:

      This answer is correct because chest pain could indicate a potential complication of pneumonia and would also impair the client’s ability to cough and deep breathe. Assessment for reports of chest pain is an important aspect of the focused respiratory assessment for a client with pneumonia.

  4. Peripheral edema.
    • Rationale:

      This answer is not correct because although assessing for peripheral edema is an appropriate aspect of a head to toe assessment, it is not the focus/priority assessment for the client with pneumonia (unless the complications are related to heart failure, kidney failure, or other comorbidities or co-diagnoses exist and this question only centered on pneumonia).

  5. Elevated temperature.
    • Rationale:

      This answer is not correct because elevated temperature is an expected finding in a client with pneumonia. Temperature assessment is included in the assessment of every client, regardless of disease process. It is not considered part of a focused respiratory assessment for a client with pneumonia.

Overview

The focus of this question is determining which assessments should be included in a focused assessment of a client with pneumonia. A focused respiratory assessment should be priority for this client.

Explanation

Learning Outcomes

Pneumonia is an infection of the lower respiratory tract, primarily affecting the alveoli. The alveoli become inflamed and fluid-filled. Typical manifestations of pneumonia include dyspnea, hypoxemia, discoloration of the skin and nail beds, a cough, chest pain, and diminished breath sounds upon auscultation. A focused respiratory assessment would reveal discolored nail beds, adventitious breath sounds, and reports of chest pain.

Test Taking Tip

When answering, select all that apply questions, it is helpful to look at each answer choice individually while covering up the remainder of the options.

Video Rationale