Physiological Adaptation Practice Question

Question

The nurse is caring for a client with heart failure and is focused on oxygen therapy scenario 3. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Delegate the clinical assessment and nursing judgment to assistive personnel.
3. C. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
4. D. Verify device settings, skin integrity, and response to therapy.

Correct Answer

D. Verify device settings, skin integrity, and response to therapy.

Explanation

The priority action for oxygen therapy is to verify device settings, skin integrity, and response to therapy. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: hard
• Domain: Physiological Adaptation
• Objective: oxygen therapy

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