A client reports difficulty breathing, stating, 'I can’t catch my breath.' What is the most appropriate action for the nurse to take?

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: 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.

Correct Answer: C

Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy. Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS. Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent. Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.

Correct Answer: A

Rationale: Step 1: Type A blood has been associated with a slightly higher risk of developing gastric cancer compared to other blood types. Step 2: The nurse mentioned a 10% increase in risk, which aligns with the increased risk associated with Type A blood. Step 3: Type AB and Type B blood do not have the same increased risk for gastric cancer as Type A blood. Step 4: Type O blood is actually associated with a lower risk of gastric cancer compared to Type A blood. Step 5: Therefore, the correct answer is A: Type A blood.

Correct Answer: D

Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation. Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.

Correct Answer: A

Rationale: The correct answer is A because reassessing the client's diet, medication, and lifestyle habits allows the nurse to identify any factors contributing to the elevated blood glucose levels. By identifying possible issues, the nurse can make necessary adjustments to the treatment plan to better manage the client's condition. Increasing medication dosage without understanding the root cause may lead to adverse effects. Simply documenting the elevated levels without taking proactive measures does not address the problem. Notifying the client's family is not the nurse's first action; the focus should be on assessing and addressing the client's needs.

Correct Answer: D

Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.

Correct Answer: D

Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange. Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.

Correct Answer: A

Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.