The nurse provides care for a client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?

Choice A reason: Instructing repositioning every 2 hours is appropriate but not the first action for a progressing ulcer, seen on video. Verification via in-person assessment ensures accuracy, as video may not capture depth or infection. A home visit confirms the stage, guiding intervention, per pressure ulcer management protocols.

Choice B reason: Asking the daughter to take pictures is unreliable, as non-professional images may lack clarity or accuracy. A nurse’s in-person assessment is needed to evaluate ulcer progression, ensuring proper staging and treatment, avoiding misdiagnosis, per telehealth and wound care standards.

Choice C reason: Contacting the provider for a hydrocolloid dressing is premature without verifying the ulcer’s stage in person. Stage 1 ulcers typically require pressure relief, not advanced dressings. A home visit confirms progression, ensuring appropriate intervention, per evidence-based wound care guidelines.

Choice D reason: Making a home visit to verify ulcer changes is the priority, as video may not fully capture progression (e.g., depth, infection). In-person assessment confirms the stage, guiding accurate treatment like dressings or repositioning, preventing deterioration, per telehealth wound assessment and pressure injury protocols.

Choice A reason: Pursed lip breathing (PLB) prolongs exhalation to reduce air trapping in COPD but does not directly prevent atelectasis, which is alveolar collapse from shallow breathing or obstruction. PLB maintains positive airway pressure, improving gas exchange, but atelectasis prevention requires deep breathing exercises, making this statement incorrect for PLB’s primary function.

Choice B reason: Pucker the lips like whistling is the correct technique for pursed lip breathing, creating a small opening to slow exhalation. This increases airway pressure, preventing alveolar collapse in COPD and improving oxygen saturation. By prolonging exhalation, PLB reduces hyperinflation, enhancing respiratory efficiency, making this the accurate description of the technique.

Choice C reason: Breathing slowly through the mouth for 4 counts describes inhalation timing, not specific to pursed lip breathing’s exhalation focus. PLB involves nasal inhalation and slow exhalation through pursed lips to reduce air trapping in COPD. Incorrect inhalation instructions can disrupt the technique’s effectiveness in maintaining airway pressure and improving gas exchange.

Choice D reason: Breathing out fast through the mouth for 2 counts contradicts pursed lip breathing’s purpose of slow, controlled exhalation. Rapid exhalation in COPD exacerbates air trapping, worsening hyperinflation. PLB prolongs exhalation through pursed lips to maintain airway pressure, improving oxygenation and reducing respiratory distress, making this statement incorrect.