You are caring for a client who has just returned from surgery and has received intravenous morphine minutes before leaving the recovery room. You need to assess the client's pain now and again at which of the following times?

Correct Answer: A

Rationale: Post-morphine pain assessment at 20-30 minutes evaluates peak effect, critical post-surgery. Later checks miss this window. Nurses time this for efficacy.

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.

Correct Answer: A

Rationale: Frequent repositioning prevents pressure ulcers in immobilized patients by relieving pressure on skin over bones, boosting circulation, and reducing tissue breakdown risk. Sustaining or promoting immobility heightens this risk, as does tight dressings that add pressure and impair blood flow. Nurses implement this intervention shifting positions every two hours, for instance to protect skin integrity, a fundamental strategy in caring for those unable to move independently, prioritizing prevention over reactive treatment.

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.

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.