What instructions will you give the nursing assistant who will assist the client with ADLs? (Choose all that apply.)

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: D

Rationale: In an adult patient with bronchiectasis, a nursing assessment is likely to reveal recurrent lower respiratory tract infections. Bronchiectasis is a chronic condition characterized by abnormal widening and destruction of the bronchi, leading to impaired mucus clearance and recurrent infections. Option A, chest trauma, is not typically associated with bronchiectasis. Option B, childhood asthma, may be a risk factor for developing bronchiectasis in adulthood but is not a direct assessment finding. Option C, smoking or oral tobacco use, is a risk factor for many respiratory conditions but is not specific to bronchiectasis. Educationally, understanding the key assessment findings in bronchiectasis is crucial for nurses to provide appropriate care and interventions for patients with this condition. Recognizing the signs of recurrent lower respiratory tract infections can help guide treatment and management strategies to improve the patient's quality of life and prevent complications.

Correct Answer: B

Rationale: The correct answer is B (158 and 40 mm Hg) because the partial pressure of oxygen in inspired air is approximately 158 mm Hg, while in expired air it decreases to around 40 mm Hg due to oxygen being taken up by the body tissues for metabolism. Choice A (158 and 116 mm Hg) is incorrect because expired air has a lower partial pressure of oxygen than inspired air. Choice C (100 and 95 mm Hg) is incorrect as it does not reflect the significant decrease in oxygen partial pressure from inspired to expired air. Choice D (40 and 95 mm Hg) is incorrect as it has the values reversed, with expired air having a higher partial pressure of oxygen than inspired air, which is not physiologically accurate.

Correct Answer: B

Rationale: The correct answer is B because foetal Hb has a lower P50 (18-20 mm Hg) than adult Hb (26.6 mm Hg). A lower P50 indicates higher oxygen affinity, allowing foetal Hb to bind oxygen more readily at lower partial pressures. This shift to the left of the dissociation curve ensures efficient oxygen transfer from the maternal bloodstream to the foetus. Choices A, C, and D are incorrect because foetal Hb having a higher P50 (A), readily accepting oxygen (C), or easily removing carbon dioxide (D) would not explain the left shift in the dissociation curve.

Correct Answer: A

Rationale: The correct answer is A: Rapid shallow breathing. Tachypnoea refers to an increased respiratory rate, which can lead to shallow breathing. Rapid breathing helps to compensate for inadequate oxygen levels. Choice B is incorrect because tachypnoea is not typically associated with deep breathing. Choices C and D are incorrect as they describe slow breathing patterns, which are opposite to tachypnoea.