A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met?

Correct Answer: B

Rationale: The correct answer is B. Intact skin behind the ears indicates that the oxygen delivery device is fitted properly and not causing skin breakdown, ensuring client safety. A (meals being eaten) is not directly related to oxygen therapy outcomes. C (client understanding) is important but doesn't directly assess client safety with oxygen therapy. D (unchanged weight) is not a specific indicator of client safety with oxygen therapy.

Correct Answer: C

Rationale: The correct answer is C. The maxillary sinuses are paired cavities located on either side of the nose, beneath the orbits. Ethmoidal sinuses (A) are smaller and located between the eyes. Frontal sinuses (B) are above the eyebrows. Sphenoidal sinuses (D) are deeper within the skull, behind the nasal cavity.

Correct Answer: D

Rationale: In this scenario, option D is the most appropriate action for an experienced LPN/LVN. Evaluating the client's technique for using MDIs is within the scope of practice for an LPN/LVN as it involves assessing and ensuring proper medication administration, which is a crucial aspect of nursing care. Option A, auscultating breath sounds, is more aligned with the role of a registered nurse or respiratory therapist who have advanced assessment skills. Option B, administering MDI medications, typically falls under the responsibilities of a registered nurse or a healthcare provider with prescriptive authority. Option C, checking oxygen saturation using pulse oximetry, is also usually performed by a registered nurse or respiratory therapist who can interpret the results and make appropriate clinical decisions based on the findings. This question provides valuable educational context by highlighting the importance of understanding the scope of practice for different levels of nursing personnel and emphasizes the significance of appropriate delegation and collaboration within a healthcare team to ensure safe and effective patient care.

Correct Answer: A

Rationale: The correct answer is option A) Perform postural drainage and chest physiotherapy every 4 hours. This nursing activity is most important because it directly addresses the client's respiratory system needs. Postural drainage and chest physiotherapy help mobilize secretions, improve lung function, and prevent complications such as pneumonia in clients with respiratory issues. It is a vital component of respiratory care for clients with conditions like pneumonia, cystic fibrosis, or chronic obstructive pulmonary disease (COPD). Option B) discussing the client's feelings about a living will is not the most immediate or critical nursing activity when compared to addressing the client's respiratory needs. While discussing end-of-life care preferences is important, it is not as urgent as ensuring proper respiratory care. Option C) placing the client in a private room to decrease infection risk is a good infection control measure, but it does not directly address the client's respiratory needs or provide the necessary care for their condition. Option D) planning activities to allow uninterrupted sleep is important for overall patient well-being, but it is not as critical as managing the client's respiratory status in this scenario. In an educational context, understanding the prioritization of nursing activities is crucial for nursing students and healthcare professionals. This question highlights the importance of recognizing the immediate needs of the client and prioritizing care based on those needs. It reinforces the significance of respiratory care interventions in clients with respiratory system issues to prevent complications and promote optimal health outcomes.

Correct Answer: D

Rationale: In this scenario, the nurse should suspect a spontaneous pneumothorax is occurring. A spontaneous pneumothorax typically happens in individuals with underlying lung conditions, such as COPD, and can be triggered by smoking. In this case, the patient's history of COPD and smoking increases the likelihood of a spontaneous pneumothorax. A tension pneumothorax (Option A) is characterized by a buildup of air under pressure in the pleural space, leading to mediastinal shift and compromised cardiac output. This condition is typically associated with trauma or invasive medical procedures (Iatrogenic pneumothorax - Option B), rather than COPD and smoking. Traumatic pneumothorax (Option C) results from physical injury to the chest, which is not indicated in this patient's history. Understanding the different types of pneumothorax and their associated risk factors is crucial for nurses caring for patients with respiratory conditions. Recognizing the signs and symptoms of each type helps in prompt identification and appropriate intervention, thus improving patient outcomes. In this case, linking the patient's history with the most likely type of pneumothorax enhances critical thinking and clinical decision-making skills in nursing practice.