A nurse is assessing a client with chronic hypoxemia. Which of the following findings should the nurse expect?

Correct Answer: C

Rationale: The correct answer is C: Polycythemia. Chronic hypoxemia leads to decreased oxygen levels in the blood, causing the body to produce more red blood cells (polycythemia) to compensate for the lack of oxygen. This can result in increased blood viscosity and potential clotting issues. A: Cyanosis of the lips is more commonly seen with acute hypoxemia, not chronic hypoxemia. B: Peripheral neuropathy is not a direct consequence of chronic hypoxemia but can be seen in conditions like diabetes. D: Hyperactive deep tendon reflexes are not typically associated with chronic hypoxemia. In summary, the nurse should expect polycythemia in a client with chronic hypoxemia due to the compensatory mechanism of increased red blood cell production.

Correct Answer: A

Rationale: The correct answer is A because a PaO2/FiO2 ratio of 200 indicates severe hypoxemia in ARDS, signifying impaired gas exchange and poor oxygenation. This ratio is a key indicator of the severity of ARDS. B: Bilateral infiltrates on chest X-ray are expected findings in ARDS but do not directly reflect the severity of hypoxemia. C: A pH of 7.45 in ABG suggests normal acid-base balance, which is not as concerning as severe hypoxemia. D: A serum lactate level of 2 mmol/L is within the normal range and is not specific to ARDS or indicative of its severity.

Correct Answer: B

Rationale: The correct answer is B: Placing the client in high Fowler's position. This is the priority intervention for a client with acute respiratory failure as it helps improve lung expansion and oxygenation by maximizing chest expansion. Administering a bronchodilator (Choice A) may help with airway patency but placing the client in an upright position takes precedence. Preparing the client for intubation (Choice C) is a more invasive intervention and should be considered after optimizing non-invasive measures. Administering IV antibiotics (Choice D) may be necessary but addressing the immediate respiratory distress by positioning the client correctly is the priority.

Correct Answer: C

Rationale: The correct answer is C: Using an N95 respirator while providing care. This is because TB is an airborne disease that can spread through respiratory droplets. The N95 respirator provides the highest level of protection against inhaling these droplets. A: Wearing a surgical mask is not sufficient to protect against TB transmission as it does not filter out small infectious particles. B: Hand hygiene is important for infection control but does not specifically address airborne transmission of TB. D: Gowning and gloving may be necessary for contact precautions but do not provide adequate protection against airborne transmission of TB.

Correct Answer: A

Rationale: The correct answer is A: Monitoring for decreased breath sounds on the affected side. This is the priority assessment because pneumothorax involves the accumulation of air in the pleural space, leading to lung collapse and decreased breath sounds on the affected side. This assessment is crucial to promptly detect worsening respiratory status and the need for immediate intervention. Choice B is incorrect because while assessing for bilateral chest rise and fall is important in general respiratory assessment, it is not the priority in pneumothorax where the focus is on the affected side. Choice C is incorrect as cyanosis and tachycardia may occur later as a result of respiratory distress, but monitoring breath sounds is more direct for detecting pneumothorax. Choice D is incorrect because measuring oxygen saturation levels may not accurately reflect the severity of pneumothorax and should not be the priority assessment in this case.