A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?

A. Assessing changes in body temperature. The RN is responsible for assessing trends in temperature and identifying potential clinical implications (e.g., infection, sepsis, or medication reactions).

B. Being aware of the usual values for the patient. While knowing baseline values is important, this is not solely an RN responsibility. Nursing assistants and other healthcare providers also note baseline values.

C. Obtaining temperature measurements at ordered frequency. This task can be delegated to a nursing assistant or licensed practical nurse (LPN), as it is a routine task that does not require assessment.

D. Using an appropriate route and device. While the RN ensures correct procedures are followed, this specific task can also be performed by trained assistive personnel. The RN focuses on interpretation and intervention.

A. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development.

B. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor.

C. Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort.

D. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.