A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

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Question 1 of 5

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

Correct Answer: D

Rationale: Prolonged oxygen therapy can dry the mucous membranes, leading to cracks, discomfort, and increased infection risk, making this an adverse effect. Tachycardia (A) is more associated with hypoxia, excessive secretions (B) relate to the pneumonia itself, and poor skin turgor (C) indicates dehydration, not a direct effect of oxygen therapy.

Question 2 of 5

Which intervention can the client expect to receive from a medical-surgical nurse in an ambulatory care setting?

Correct Answer: B

Rationale: Teaching dressing changes is a primary nursing role in ambulatory care. Blood draws (A) and physicals (D) may occur but aren’t primary, and obtaining consent (C) is typically the surgeon’s responsibility.

Question 3 of 5

The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel?

Correct Answer: B

Rationale: Assisting with meals is appropriate for unlicensed assistive personnel (UAP) under the five rights of delegation. Care planning (A), evaluating oximetry (C), and assessing consciousness (D) require nursing judgment and cannot be delegated.

Question 4 of 5

A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help them be active partners in care?

Correct Answer: A

Rationale: Encouraging active participation is critical for clients to partner in their care, offering broad protection. Visiting hours (B), cafeteria directions (C), and call light use (D) are limited in scope and less impactful on overall engagement.

Question 5 of 5

A nurse delegates a client’s vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previous readings, and the clients mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

Correct Answer: C

Rationale: Proper supervision, including directing and following up, per the five rights of delegation, would have ensured timely reporting of changes. Assessing UAP skill (A) is assumed, double-checking (B) undermines delegation, and doing it herself (D) negates delegation’s purpose.

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