Physiological Adaptation Practice Question

Question

The nurse is caring for a client with shortness of breath and is focused on airway assessment scenario 4. 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. Assess respiratory effort, breath sounds, oxygen saturation, and mental status.
  4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

C. Assess respiratory effort, breath sounds, oxygen saturation, and mental status.

Explanation

The priority action for airway assessment is to assess respiratory effort, breath sounds, oxygen saturation, and mental status. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

  • Difficulty: medium
  • Domain: Physiological Adaptation
  • Objective: airway assessment

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