Nr224 Exam 2 Updated 2023

c. respirations d. gag reflex {Ans: When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? Select all that apply. a. oxygen saturation b. heart rate c. respirations d. gag reflex e. response to painful stimulus}a. oxygen saturation levels b. amount, color, and consistency of sputum production d. change in respiratory rate and pattern {Ans: The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? Select all that apply. a. oxygen saturation levels b. amount, color, and consistency of sputum production c. fluid status d. change in respiratory rate and pattern e. pain in lower leg}a. use a transfer device c. have head of bed flat when repositioning patient e. raise head of bed 30 degrees when patient positioned supine {Ans: Which of the following are measures to reduce tissue damage from shear? Select all that apply. a.