A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?

Correct Answer: B

Rationale: The correct answer is B (21%). Room air contains approximately 21% oxygen. By removing the supplemental oxygen, the client is now breathing the oxygen content present in the surrounding air. Choices A, C, and D are incorrect as they do not reflect the standard oxygen concentration in room air. Oxygen concentration in room air is typically around 21%, making choice B the most accurate option.

Correct Answer: D

Rationale: The correct answer is D: Ethambutol. Ethambutol is not used in the treatment of inhalation anthrax. The treatment of choice for inhalation anthrax is a combination of antibiotics such as ciprofloxacin, doxycycline, and sometimes vancomycin. Ethambutol is primarily used in the treatment of tuberculosis, not anthrax. It is important for the nurse to be knowledgeable about the appropriate medications for specific conditions to provide effective care.

Correct Answer: A

Rationale: The correct answer is A. Applying an immobilization device after physician evaluation helps stabilize the rib and reduce pain. B (discouraging deep breaths) is harmful as it can lead to atelectasis. C (advising against analgesics) is incorrect because pain management is essential. D (increasing fluid intake) is secondary and depends on the presence of pulmonary complications.

Correct Answer: D

Rationale: In this scenario, option D is the correct answer for the nursing assistant to follow when assisting a client with activities of daily living (ADLs). Using a rectal thermometer to attain a more accurate body temperature is crucial because rectal temperature is considered the most accurate reflection of core body temperature. This is especially important in clients with respiratory issues as changes in body temperature can indicate infection or other health concerns that need immediate attention. The other options (A, B, C) are incorrect for the following reasons: - Option A: Using a lift sheet when moving and positioning the client in bed is important for preventing injury and ensuring proper body mechanics, but it is not directly related to respiratory care. - Option B: Using an electric razor when shaving the client daily is a good practice for skin care but does not directly impact respiratory health. - Option C: Using a soft-bristled toothbrush or tooth sponge for oral care is important for maintaining oral hygiene but is not specifically related to respiratory care. Educationally, it is essential for nursing assistants to understand the rationale behind each task they perform when caring for clients, especially those with respiratory issues. By knowing why certain actions are taken, they can provide better holistic care and contribute to the overall well-being of the client. In this case, accurate body temperature measurement is crucial for monitoring the client's health status, particularly in respiratory conditions where even minor changes can be significant indicators of potential complications.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) SpO of 86%. Impaired gas exchange is a common nursing diagnosis in patients with pneumonia because it indicates the inadequate oxygenation of blood and elimination of carbon dioxide. A low SpO2 level (less than 90%) is a critical finding that indicates poor oxygen saturation in the blood, directly related to impaired gas exchange. This finding reflects the inability of the lungs to effectively oxygenate the blood and remove carbon dioxide, which are key functions of the respiratory system. Option B, crackles in both lower lobes, is associated with pneumonia but specifically suggests fluid or mucus in the alveoli or bronchioles, which may impair ventilation but does not directly reflect impaired gas exchange. Option C, a temperature of 101.4°F (38.6°C), is indicative of infection but does not directly relate to gas exchange. Option D, production of greenish purulent sputum, is more indicative of an infectious process rather than impaired gas exchange. Educationally, understanding how to identify impaired gas exchange is crucial for nurses caring for patients with respiratory conditions like pneumonia. Recognizing the significance of SpO2 levels in assessing gas exchange helps nurses intervene promptly to improve oxygenation and prevent further complications. It also underscores the importance of thorough assessment and critical thinking in nursing practice to provide appropriate and timely care for patients with respiratory issues.