Correct Answer: A

Rationale: The correct answer is A because measuring oxygen saturation will provide objective data to assess the client's respiratory status accurately. This step is crucial in identifying the severity of the client's breathing difficulty and determining the appropriate intervention. Encouraging deep breathing exercises (
B) may worsen the client's condition if there is an underlying respiratory problem. Simply documenting the client's statement (
C) without immediate action can delay necessary interventions. Providing oxygen without further assessment (
D) can be harmful if the client's oxygen saturation is already high. Overall, option A is the most appropriate as it involves a proactive and evidence-based approach to address the client's reported breathing difficulty.

Correct Answer: A

Rationale:
Correct Answer: A: Respiratory acidosis


Rationale:
1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO₂ and decreased pH.
2. Low pH indicates acidosis, and high PCO₂ indicates respiratory component.
3. Metabolic acidosis (
B) results from non-respiratory causes.
4. Respiratory alkalosis (
C) is characterized by high pH and low PCO₂.
5. Metabolic alkalosis (
D) is caused by non-respiratory factors with high pH.

Correct Answer: C

Rationale: The correct answer is C, hyperglycemia and hypokalemia. Hyperglycemia can occur in adult clients due to various factors such as diabetes or stress. Hypokalemia can be a consequence of hyperglycemia or other conditions leading to potassium loss. Monitoring for these metabolic complications is essential to ensure the client's well-being. Other choices are incorrect because hypoglycemia and hypercalcemia (choice
A) are less likely to occur concurrently in adult clients. Hyperglycemia and hyperkalemia (choice
B) are less common as hyperkalemia is usually associated with renal dysfunction. Hyperkalemia and hypercalcemia (choice
D) are less likely to be monitored together as they are not commonly seen in the same clinical context.

Correct Answer: A

Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line.
Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet.



Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet.

Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.

Correct Answer: C

Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease.


Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites.
Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites.
Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.