Ch 17: Implementing
The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? A) Registered nurse B) Nursing assistant C) A senior nursing student present for clinical D) Licensed practical nurse
B) Nursing assistant
The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? A) Begin using the technique to determine whether it is effective. B) Petition to change the protocol based on the new evidence. C) Ask the ER physician to order IM injections with the new technique. D) Research the protocols at other area emergency rooms.
B) Petition to change the protocol based on the new evidence.
Which is an independent (nurse-initiated) action? A) Executing physician orders for a catheter B) Meeting with other health care professionals to discuss a client C) Helping to allay a client's fears about surgery D) Administering medication to a client
C) Helping to allay a client's fears about surgery
Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A) Record the client's intake and output. B) Assess the client's need for education. C) Assist the client to the bedside commode. D) Assess the client's risk for pressure injuries. E) Administer routine oral medications.
A) Record the client's intake and output. C) Assist the client to the bedside commode.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? A) Does this task fall within the scope of a UAP? B) What is the client's condition? C) How can I supervise the completion of this task? D) How can I explain the task to the UAP?
A) Does this task fall within the scope of a UAP?
An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply. A) Initial assessment of the mother after birth of the infant B) Assisting the client with personal hygiene needs and ambulation C) Assisting and teaching the client to breastfeed the infant D) Providing routine discharge instructions related to infant care E) Transporting the infant to the mother's room according to hospital policy
B) Assisting the client with personal hygiene needs and ambulation E) Transporting the infant to the mother's room according to hospital policy
The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? A) The client calls for assistance to get out of bed. B) The client is free of falls. C) The client is taught safety precautions. D) The client verbalizes risks for injury.
B) The client is free of falls.
The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? A) Supportive B) Surveillance C) Collaborative D) Maintenance
B) Surveillance
The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? A) "I will report your concerns to the nurse manager." B) "I will discuss your concerns with the night nurse." C) "You should always speak up if you have any questions about your care." D) "You always have the right to refuse any medication or treatment."
C) "You should always speak up if you have any questions about your care."
The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? A) The client expresses a desire to learn how to manage the medication regime. B) The parents verbalize acceptance of the need to closely monitor their child's condition. C) The parents have comprehensive insurance coverage for their family's medical care. D) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
D) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? A) Revise the care plan to allow the client to ambulate to the bathroom independently. B) Continue assisting the client to the bathroom to ensure the client's safety. C) Consult with the physical therapist to determine the client's ability. D) Instruct the client's family to assist the client to ambulate to the bathroom.
A) Revise the care plan to allow the client to ambulate to the bathroom independently.
A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? A) The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. B) The nurse should ask another nurse who was previously assigned to the client for instruction. C) The nurse should request that the blood transfusions be delayed until the next shift. D) The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.
A) The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? A) Continue the education and remind the client that it is essential to learn self-care. B) Medicate the client for anxiety and continue the education later. C) Discontinue the education and attempt at another time. D) Discontinue the education and ask the client for permission to teach a family member.
C) Discontinue the education and attempt at another time.
The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? A) Providing medication for agitation B) Repositioning to prevent pressure injuries C) Ensuring that the endotracheal tube is secure D) Changing the dressing to prevent infection
C) Ensuring that the endotracheal tube is secure
The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? A) Teach the content again utilizing the same method. B) Reassess the appropriateness of the method of instruction. C) Revise the plan to include the inclusion of a support group. D) Report the client's inability to learn to the case manager.
B) Reassess the appropriateness of the method of instruction.
A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? A) Restrict intake of foods and fluids. B) Monitor for noncompliance. C) Monitor for lactic acidosis D) Administer B12 injections
C) Monitor for lactic acidosis
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? A) Go to the client and assess the client's pain. B) Determine the frequency of pain medication. C) Medicate the client with the ordered pain medication. D) Instruct the client in nonpharmacologic pain management.
A) Go to the client and assess the client's pain.
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? A) Finances of the client B) The client's condition C) Time and resources D) Feedback from the family
A) Finances of the client
The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client understands proper wound care techniques? A) Include family members or other caregivers in the education. B) Delegate teaching to unlicensed assistive personnel (UAP). C) Provide a video demonstration of abdominal wound care. D) Document client education prior to discharge from the unit.
A) Include family members or other caregivers in the education.
The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? A) Determine the client's reaction to the medication in the past. B) Assess the client's blood pressure to determine if the medication is indicated. C) Ask the client to verbalize the purpose of the medication. D) Tell the client to report any side effects experienced.
B) Assess the client's blood pressure to determine if the medication is indicated.
The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? A) Registered nurse B) Nursing assistant who is a nursing student C) A senior nursing student present for clinical D) Licensed practical nurse
B) Nursing assistant who is a nursing student
The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? A) Assess the client's response to the ambulation. B) Inform the client when ambulation is scheduled next. C) Discuss the client's feelings about the illness. D) Document the client's ambulation.
A) Assess the client's response to the ambulation.
A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? A) Recognize the nurse's own limitations and ask for another nurse to be assigned. B) Recognize that the nurse may be faced with this issue again and care for the client. C) Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. D) Recognize the issue and care for the client to the best of the nurse's ability.
A) Recognize the nurse's own limitations and ask for another nurse to be assigned.
A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? A) Report the findings to the physician for further plans. B) Reinforce the instructions for the treatment regimen to the client. C) Interview the family to determine if the client is giving accurate information. D) Inform the client that the blood pressure medication will have to be changed.
A) Report the findings to the physician for further plans.
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? A) Nurse manager B) Nurse case manager C) Physician D) Insurance company
B) Nurse case manager
The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? A) Take the vital signs of the client who just returned from surgery. B) Feed a client who is eating for the first time following an ischemic stroke. C) Bathe a client with stable angina who has a continuous IV infusing. D) Assist the client who is ambulating the first time since hip replacement surgery.
C) Bathe a client with stable angina who has a continuous IV infusing.
Which statement best explains why continuing data collection is important? A) It is difficult to collect complete data in the initial assessment. B) It is the most efficient use of the nurse's time. C) It enables the nurse to revise the care plan appropriately. D) It meets current standards of care.
C) It enables the nurse to revise the care plan appropriately.
Which parties are essential for the nurse to include in the implementation of a client's plan of care? A) Client, family, and physician B) Client, physician, and hospital director C) Client, physical therapist, and nursing staff D) Client, surgeon, and physician
A) Client, family, and physician
A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? A) Ask the client how the bag is changed. B) Read the policy and procedure manual. C) Ask a skilled nurse to assist with the procedure. D) Determine the necessity of the bag change.
C) Ask a skilled nurse to assist with the procedure.
The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide? A) Arranging for clergy to visit with the client B) Teaching the client how to administer medications C) Providing humor in conversation to assist in alleviating stress D) Arranging appointments with a specialist after the client is discharged
A) Arranging for clergy to visit with the client
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? A) Assess the client to determine the cause of the pain. B) Consult with the physician for additional pain medication. C) Discuss the frequency of pain medication administration with the client. D) Assist the client to reposition and splint the incision.
A) Assess the client to determine the cause of the pain.
The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? A) Delay the instruction until the visitors leave. B) Give the visitors instructions to leave in 10 minutes. C) Ask the client if the client has any questions. D) Leave written information for the client to read later.
A) Delay the instruction until the visitors leave.
A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? A) Determine the client's willingness to follow the regimen. B) Identify changes from the baseline. C) Ensure physician approval for the education plan. D) Instruct the unlicensed assistive personnel on what to teach the client.
A) Determine the client's willingness to follow the regimen.
Which is the priority question for the nurse to consider before implementing a new intervention? A) Does this treatment make sense for this client? B) How much experience do I have with this treatment? C) What equipment do I need? D) Will I need someone to assist me?
A) Does this treatment make sense for this client?
A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? A) Discuss the risks and benefits of a blood transfusion with the client. B) Discuss possible alternatives to a blood transfusion with the physician. C) Discuss the client's options with other church members. D) Discuss the client's refusal with hospital risk managers.
B) Discuss possible alternatives to a blood transfusion with the physician.
A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaurant bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? A) Explain the effects of a high-salt diet and smoking on blood pressure. B) Identify what barriers the client feels are preventing adherence with the plan. C) Collaborate with other health care professionals about the client's treatment. D) Change the nursing care plan.
B) Identify what barriers the client feels are preventing adherence with the plan.
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? A) Discuss discharge plans with the client. B) Inform the client what to expect after the surgery. C) Instruct the client and family in wound care. D) Teach the client about dietary restrictions during recovery.
B) Inform the client what to expect after the surgery.
The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit? A) Right task B) Right circumstance C) Right person D) Right supervision
B) Right circumstance
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? A) Algorithm B) Standing orders C) Protocol D) Order set
B) Standing orders
When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? A) "It is a habit that nurses develop in school." B) "It is a hospital policy to reduce the potential for errors." C) "We ask your name to ensure that we are treating the right client." D) "We ask your name to show that we respect your rights."
C) "We ask your name to ensure that we are treating the right client."
A nurse is providing care to several assigned clients and decides to delegate the task of monitoring vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? A) An older adult with pneumonia who is being discharged to the son's home tomorrow B) A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall C) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen D) An adult client who is being treated for kidney stones
C) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? A) Secure the client's jewelry before surgery. B) Reassess the client's sacrum for redness when doing a bed bath. C) Provide the client with assistance in transferring to the bedside commode. D) Retrieve a unit of blood from the blood bank.
C) Provide the client with assistance in transferring to the bedside commode.
The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. A) The client is male. B) The client is married. C) The client is blind. D) The client is an architect. E) The client denies the need for education.
C) The client is blind. E) The client denies the need for education.
Which nursing action can be categorized as a surveillance or monitoring intervention? A) Providing hygiene B) Administering a paracetamol tablet C) Auscultating of bilateral lung sounds D) Use of therapeutic communication skills
C) Auscultating of bilateral lung sounds
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? A) "I provide indirect care to my clients by coordinating their treatment with other disciplines." B) "Even though I do not provide care to clients, my work is very important." C) "I provide a critical service that is necessary for financial reimbursement." D) "Moving away from client care is a necessary step to advancing my career."
A) "I provide indirect care to my clients by coordinating their treatment with other disciplines."
Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? A) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners B) Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose C) Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment D) Changing a client's advance directive after the prognosis has significantly worsened
A) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? A) Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. B) Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. C) Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. D) Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.
B) Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? A) Medications used to treat diabetes mellitus B) Risk factors for and prevention of diabetes mellitus C) The severity of the client's disease D) The cellular metabolism of glucose
B) Risk factors for and prevention of diabetes mellitus
The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? A) Remind the client that the client is responsible for the client's own health care decisions. B) Ask the client whether the client is afraid that the spouse will be angry. C) Ask the surgeon to wait until the client has had a chance to talk to the spouse. D) Inform the surgeon that the nurse will not sign the informed consent form.
C) Ask the surgeon to wait until the client has had a chance to talk to the spouse.
The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety? A) Remove all the cluttered objects from the pathway to the client's bathroom. B) Instruct the client about the need to keep the walkway to the bathroom clear. C) Assist the client to identify strategies to promote safety in the home. D) Assign a home health aide to perform housekeeping duties.
C) Assist the client to identify strategies to promote safety in the home.
The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse mostappropriately remedy this conflict? A) Assess the client to determine whether the client is capable of ambulation. B) Instruct the client to ask the physicians for clarifications of instructions. C) Communicate with the physicians to coordinate their orders. D) Collaborate with the physical therapist to determine the client's ability.
C) Communicate with the physicians to coordinate their orders.
A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? A) Surveillance B) Supportive C) Coordinating D) Technical
C) Coordinating
The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? A) Review with the client the risks and benefits of surgery. B) Ask the client to discuss the decision with family members. C) Discuss with the client the reasons for declining surgery. D) Notify the physician of the client's refusal.
C) Discuss with the client the reasons for declining surgery.
The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? A) Ambulate the client and medicate later. B) Emphasize to the client the importance of following the treatment plan. C) Medicate the client and wait to ambulate later. D) Explain to the client the benefits of ambulation.
C) Medicate the client and wait to ambulate later.
When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? A) Inform the client that it is not necessary to wash hands before vital signs. B) Reassure the client that the nurse knows when to perform hand hygiene. C) Praise the client for taking an active role in the client's care. D) Tell the client that gloves are required for this procedure.
C) Praise the client for taking an active role in the client's care.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? A) The client who needs vital signs taken following infusion of packed red blood cells. B) The client who requires assistance dressing in preparation for discharge. C) The client with continuous pulse oximetry who requires pharyngeal suctioning. D) The client who is pleasantly confused and requires assistance to the bathroom.
C) The client with continuous pulse oximetry who requires pharyngeal suctioning.
The primary purpose of nursing implementation is to: A) improve the client's postoperative status. B) identify a need for collaborative consults. C) help the client achieve optimal levels of health. D) implement the critical pathway for the client.
C) help the client achieve optimal levels of health.
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? A) Bed bath for the newly admitted client who has multiple skin lesions B) Preparation of insulin for the diabetic client with an elevated blood glucose level C) Ambulation of the client with a history of falls for the first time after surgery D) Insertion of a urinary catheter in a client with benign prostatic hypertrophy
A) Bed bath for the newly admitted client who has multiple skin lesions
A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's mostappropriate action? A) Coordinate with the other disciplines to schedule the tests with adequate rest for the client. B) Coordinate with the other disciplines to determine if all the tests scheduled are necessary. C) Review the physician's progress notes to determine if any of the tests are not indicated. D) Instruct the client to refuse the diagnostic tests if the client becomes too fatigued.
A) Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? A) Encourage the client to provide as much self-care as possible. B) Perform all care activities for the client to facilitate rest. C) Teach the family to anticipate the client's needs to care for the client. D) Arrange with the nurse case manager for an early discharge.
A) Encourage the client to provide as much self-care as possible.
A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? A) Reassess the client to determine the effectiveness of the interventions. B) Instruct the client that pain medication is available at regular intervals. C) Notify the physician that the client has required pain medications. D) Perform additional nonpharmacological pain interventions.
A) Reassess the client to determine the effectiveness of the interventions.
A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? A) Tell the UAP that the RN will assist the UAP with the client's ambulation. B) Tell the UAP that a different UAP should ambulate the client. C) Tell the UAP not to ambulate the client at this time. D) Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation.
A) Tell the UAP that the RN will assist the UAP with the client's ambulation.
What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply. A) The client verbalizes understanding of the instructions. B) The client is able to answer the nurse's questions. C) The client asks the nurse to repeat the instructions. D) The client tells the nurse that the client's spouse will handle the care. E) The client discusses the specifics of what was taught during the session.
A) The client verbalizes understanding of the instructions. B) The client is able to answer the nurse's questions. E) The client discusses the specifics of what was taught during the session.
The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. A) The client's respiratory rate decreases. B) The client states, "I can breathe easier now." C) The client's oxygen saturation level increases. D) The client is watching television. E) The client's family asks if the client is going to be okay.
A) The client's respiratory rate decreases. B) The client states, "I can breathe easier now." C) The client's oxygen saturation level increases.
