A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

A.Observe for signs and symptoms of respiratory distress.

B.Auscultate anterior and posterior lung fields.

C. Inspect the skin for pallor and cyanosis.

E. Observe rate, rhythm, and depth of respirations.

When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.

A. Use only written communication whenever possible to minimize the client's frustration.Written communication can be helpful in some situations, but it should not be the primary mode of communication for clients with moderate hearing loss unless necessary.

B. Minimize background noises such as the television and ensure that lighting is adequate to see the nurse's face.Reducing background noise and ensuring proper lighting are critical strategies for effective communication with individuals with hearing loss. These steps make it easier for the resident to hear and understand, and they also allow the resident to use visual cues, such as lip-reading, to enhance communication.

C. Use vocabulary and concepts that are as simple as possible.
While simplifying vocabulary may help some individuals, it is not necessary or beneficial for all residents with hearing loss. This could come across as condescending unless it aligns with the client’s cognitive ability.

D. Repeat each direction or question multiple times, even if the client states he heard and understands the directions: Repeating unnecessarily can be frustrating and counterproductive for the client. It is more effective to ensure the initial communication is clear and check for understanding without excessive repetition unless the resident indicates they need clarification.