You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process?
A) Achieve SaO2 ? 92% at all times.
B) Auscultate chest q4h.
C) Administer oral fluids q1h and PRN.
D) Avoid overexertion at all times.
Ans: A
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The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.
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