Which assessment finding indicates a potential complication of immobility related to the respiratory system?

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Question 1 of 5

Which assessment finding indicates a potential complication of immobility related to the respiratory system?

Correct Answer: C

Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.

Question 2 of 5

A client is receiving oxygen therapy via a nasal cannula. What is the appropriate flow rate for this client?

Correct Answer: B

Rationale: A flow rate of 4-6 liters per minute (B) is appropriate for nasal cannula oxygen therapy, delivering 36-44% oxygen, suitable for moderate hypoxemia. 1-2 L/min (A) (24-28%) suits mild cases or rest. 8-10 L/min (C) exceeds nasal cannula capacity, causing discomfort. 12-15 L/min (D) is for high-flow systems, not cannulas. This range balances efficacy and tolerance, per respiratory care standards, ensuring adequate oxygenation without nasal irritation.

Question 3 of 5

A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?

Correct Answer: D

Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.

Question 4 of 5

The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?

Correct Answer: C

Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.

Question 5 of 5

The nurse is caring for a client receiving oxygen therapy via a nasal cannula. Which action by the nurse is appropriate when providing oral care to the client?

Correct Answer: A

Rationale: Removing the nasal cannula during oral care (A) allows thorough hygiene without interference, briefly tolerable given short duration. Increasing flow (B) is unnecessary. Petroleum jelly (C) isn't for oral care. Mouth breathing (D) isn't needed if removed. Removal, per nursing practice, ensures effective care.

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