A Patient with Pneumonia Is Having Difficulty Maintaining a Clear

A patient with pneumonia is having difficulty maintaining a clear airway. Which actions should the nurse take to ensure this patient is adequately ventilated?

A) Assess skin color at least every four hours.
B) Assess breath sounds at least every four hours.
C) Assess oxygen saturation level at least every four hours.
D) Assess vital signs daily.
E) Assess respiratory rates every shift.