The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

Choice A rationale
The absence of coarse crackles is not necessarily an indication that chest physiotherapy (CPT) has been effective for a client with chronic obstructive pulmonary disease (COPD). Coarse crackles are often heard in conditions where there is fluid in the airways, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways, it does not necessarily mean that secretions have been effectively mobilized.
Choice B rationale
An increase in breath sounds is a good indication that chest physiotherapy (CPT) has been effective for a client with COPD3. CPT is a group of therapies designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system. When these secretions are effectively mobilized and removed, breath sounds can become clearer and more easily heard.
Choice C rationale

The absence of fine crackles is not necessarily an indication that CPT has been effective for a client with COPD. Fine crackles are often heard in conditions where there is fluid in the airways or alveoli, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways or alveoli, it does not necessarily mean that secretions have been effectively mobilized.
Choice D rationale
An increase in respiratory rate is not necessarily an indication that CPT has been effective for a client with COPD. In fact, an increased respiratory rate could indicate respiratory distress, which could suggest that the therapy has not been effective or that the client’s condition has worsened.

Choice A rationale
A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs.
Therefore, it is crucial to inquire if the patient is experiencing any pain during urination.
Choice B rationale

While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients.
Therefore, this option is not a necessary immediate action for the nurse to take.
Choice C rationale
Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior.
Choice D rationale
A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall.
Choice E rationale
Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation.
Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.