What is correct about pulse oximetry measurement?

Correct Answer: A

Rationale: The correct answer is A because a normal oxygen saturation range is between 95-98%. This range indicates adequate oxygen levels in arterial blood. Choice B is incorrect because oximetry measures oxygen saturation of arterial blood, not venous blood. Choice C is incorrect as fasting is not required for pulse oximetry. Choice D is incorrect as pulse oximetry is a non-invasive tool used for quick oxygen saturation monitoring, not a replacement for arterial blood gas analysis.

Correct Answer: A

Rationale: The correct answer is A: Physical activity. Lifestyle-related diseases, such as heart disease and type 2 diabetes, are often linked to common risk factors like smoking, genetics, and poor nutrition. However, physical activity is not a risk factor but rather a protective factor that can help prevent these diseases. Regular exercise can improve cardiovascular health, manage weight, and reduce the risk of chronic conditions. Therefore, physical activity does not fit the criteria of a common risk factor shared by lifestyle-related diseases. Smoking, genetics, and poor nutrition are directly associated with an increased risk of developing such diseases.

Correct Answer: B

Rationale: The correct answer is B: Umbilicus. When performing a rectal procedure, the rectal tip should be directed towards the umbilicus for proper insertion into the rectum. The umbilicus is used as a landmark to guide the rectal tip into the correct position. Directing the tip towards the sigmoid (A) or large intestine (D) would be incorrect as it may lead to improper insertion. Choosing the rectum (C) is not specific enough as the rectal tip needs to be aimed towards a more precise point for accurate placement.

Correct Answer: C

Rationale: The correct nursing diagnosis of "Excessive fluid volume" takes highest priority for the client with chronic renal failure due to the presenting signs and symptoms of fluid overload: high blood pressure, neck vein distention, and bibasilar crackles indicating fluid in the lungs. Managing fluid volume is crucial to prevent complications such as pulmonary edema and worsening renal function. Fear (A) is not the priority as physiological needs should be addressed first. Urinary retention (B) is not the priority as the client's symptoms are more indicative of fluid overload rather than urinary retention. Self-care deficient: Toileting (D) is not the priority as it does not address the immediate physiological threat posed by excessive fluid volume.

Correct Answer: A

Rationale: The correct answer is A: By indenting the skin ½" to ¾" (1.3 to 1.9 cm). Light palpation is performed by gently pressing down on the skin with the fingertips to a depth of ½" to ¾" to assess superficial structures. This depth allows the nurse to feel for tenderness, texture, temperature, and moisture without causing discomfort or disrupting deeper tissues. Choices B, C, and D are incorrect because they describe depths or techniques that are too deep or not appropriate for light palpation, which should be gentle and shallow. Option B (1" to 2") and C (1" using both hands) would be too deep and could potentially cause discomfort to the patient. Option D (1" and then releasing quickly) does not maintain the consistent light pressure needed for accurate assessment of superficial structures.