The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.

Correct Answer: A

Rationale: In this NCLEX question on oxygen therapy, the correct answer is option A) Excessive rapid breathing. Tachypnea is defined as abnormally rapid breathing. This is a key indicator of respiratory distress or an underlying issue affecting the respiratory system. Clients experiencing tachypnea may have an increased respiratory rate above the normal range. Options B, C, and D are incorrect. Chest pain (B) is more commonly associated with conditions like pneumothorax or cardiac issues rather than tachypnea specifically. Cyanosis (C) is the bluish discoloration of the skin or mucous membranes due to inadequate oxygenation, which can occur in hypoxemia but is not a direct indicator of tachypnea. Shallow breathing (D) refers to a decreased depth of breathing, which is not specific to tachypnea. Educationally, understanding the clinical manifestations of tachypnea is crucial for nurses to recognize respiratory distress in clients. Assessing respiratory rate, depth, and pattern is vital in providing timely interventions and monitoring the client's oxygenation status. By differentiating between tachypnea and other respiratory symptoms, nurses can effectively manage and prioritize care for clients experiencing respiratory distress.

Correct Answer: C

Rationale: Educational Rationale: The correct answer is C) Administer pancreatic enzymes. The rationale for this is that pancreatic enzymes are not directly related to the management of thick mucus secretions in cystic fibrosis. Pancreatic enzymes are typically prescribed to help with the digestion of food as individuals with cystic fibrosis often have pancreatic insufficiency. Therefore, this intervention is not directly related to addressing the issue of thick mucus secretions. A) Encouraging increased fluid intake is essential in cystic fibrosis as it helps to thin out the mucus, making it easier to clear from the airways. This intervention is appropriate for managing thick mucus secretions. B) Scheduling aerosol therapy is crucial in cystic fibrosis as it helps deliver medication directly to the lungs, which can help loosen and mobilize the thick mucus. This intervention is appropriate for managing thick mucus secretions. D) Performing percussion on the client's back and chest is a form of chest physiotherapy that helps loosen and mobilize thick mucus in the lungs, making it easier to clear from the airways. This intervention is appropriate for managing thick mucus secretions. Educational Context: Understanding the appropriate nursing interventions for managing thick mucus secretions in cystic fibrosis is crucial for providing effective care to these patients. Encouraging increased fluid intake, scheduling aerosol therapy, and performing percussion can help improve airway clearance and respiratory function in individuals with cystic fibrosis. Administering pancreatic enzymes, while important for digestion, is not directly related to managing thick mucus secretions in this context. Identifying and implementing appropriate interventions based on the specific needs of patients with cystic fibrosis is essential for promoting optimal health outcomes.

Correct Answer: C

Rationale: The correct answer to the question is C) when an autopsy fails to find a cause of death. This is because Sudden Infant Death Syndrome (SIDS) is a diagnosis of exclusion, meaning that it can only be determined after ruling out all other possible causes of death through a thorough autopsy and investigation. SIDS is a complex phenomenon that is not fully understood, but it is characterized by the sudden and unexpected death of an apparently healthy infant under 1 year of age. Option A) seemingly during play is incorrect because SIDS occurs during sleep, not during play. Option B) following a recent immunization is incorrect because although immunizations may be a concern for some parents, there is no proven link between immunizations and SIDS. Option D) when an infant is found dead in their crib is incorrect because while SIDS deaths often occur during sleep in a crib, the key defining factor is the inability to identify a cause of death upon autopsy. Educationally, understanding SIDS is crucial for healthcare professionals working with infants and young children. It is important to educate parents and caregivers about safe sleep practices to reduce the risk of SIDS, such as placing infants on their backs to sleep, using a firm sleep surface, and avoiding soft bedding and overheating. By understanding the criteria and characteristics of SIDS, healthcare providers can better support families who have experienced the tragic loss of a child due to SIDS and help to promote safe sleep environments for all infants.

Correct Answer: A

Rationale: The correct answer is A) Atmosphere, Hydrosphere, Biosphere, Lithosphere. This is because oxygen, as a vital element for life on Earth, is distributed across various reservoirs. The atmosphere contains oxygen in the form of O2 gas, which is essential for respiration. Oxygen is also dissolved in the hydrosphere, primarily in bodies of water, supporting aquatic life. Within the biosphere, oxygen is utilized by living organisms through processes like photosynthesis and cellular respiration. Additionally, the lithosphere, which includes the Earth's crust, contains oxygen in minerals and rocks. Option B) Atmosphere only is incorrect because oxygen is not exclusively found in the atmosphere but also in the other mentioned reservoirs. Option C) Biosphere and Lithosphere is incorrect as it excludes the atmosphere and hydrosphere, which are significant oxygen reservoirs. Option D) None of the above is incorrect as all the listed reservoirs play a crucial role in storing and cycling oxygen in the environment. Understanding the primary reservoirs of oxygen is essential in healthcare, particularly in oxygen therapy where patients receive supplemental oxygen to support their respiratory function. Knowing where oxygen comes from and how it is naturally distributed can aid healthcare providers in ensuring proper oxygen delivery to patients in need. This knowledge also highlights the interconnectedness of Earth's systems and the importance of oxygen for sustaining life on our planet.

Correct Answer: A

Rationale: The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.