Correct Answer: D

Rationale: Anemia can lead to an increased respiratory rate. In anemia, there are decreased levels of hemoglobin in red blood cells, which are responsible for carrying oxygen to the body's tissues.
To compensate for the reduced oxygen-carrying capacity, the body increases the respiratory rate to bring in more oxygen.

Stooped posture (
Choice
A) is not directly related to an increased respiratory rate. Narcotic analgesics (
Choice
B) are more likely to cause a decreased respiratory rate due to their central nervous system depressant effects. Injury to the brain stem (
Choice
C) can affect respiratory function but may not necessarily lead to an increased respiratory rate.

Correct Answer: C

Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line.


Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure.
Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation.
Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.

Correct Answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body.
Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis.
Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in
Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

Correct Answer: B

Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test.
Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.

Correct Answer: B

Rationale: In disseminated intravascular coagulation (DI
C), a client experiences widespread clotting throughout the body, leading to the depletion of clotting factors and platelets. A prolonged prothrombin time (PT) is a common finding in DIC. The PT measures the extrinsic pathway of the clotting cascade and reflects how quickly blood can clot. In DIC, the consumption of clotting factors results in a prolonged PT, indicating impaired clotting ability. Elevated fibrinogen levels (
Choice
A) are typically seen in the early stages of DIC due to the body's attempt to compensate for clot breakdown. Elevated platelet count (
Choice
C) is not a typical finding in DIC as platelets are consumed during the widespread clotting. A depressed d-dimer level (
Choice
D) is also not expected in DIC as d-dimer levels are elevated due to the breakdown of fibrin clots.
Therefore, the correct answer is a prolonged PT.