The nurse uses gait belts when assisting clients to ambulate. A likely candidate for this assistive device is:

Correct Answer: B

Rationale: A gait belt supports clients who can ambulate with assistance, like those with leg strength. Bedrest clients (A) don’t ambulate. Incisions (C, D) don’t necessitate it unless mobility is impaired.

Correct Answer: C

Rationale: Myocardial infarction results from reduced coronary artery blood flow, causing ischemia. The nurse focuses on the coronary artery to restore oxygenation to the heart muscle, not the vena cava, pulmonary artery, or carotid artery.

Correct Answer: C

Rationale: A respiratory rate of 8 is abnormally low (hypoventilation). Checking pulse oximetry first assesses oxygenation status, guiding further actions like oxygen administration or physician notification.

Correct Answer: B

Rationale: Accessory muscle use (e.g., neck, shoulders) suggests respiratory distress, as the patient struggles to breathe, not normal breathing, improved oxygenation, or mere fatigue.

Correct Answer: A

Rationale: Anemia reduces hemoglobin, the oxygen-carrying component of blood, directly impairing oxygenation, unlike blood pressure, airway issues, or fluid overload.