A 49-year-old male patient has been experiencing flu-like symptoms, including fever and chest congestion, for the past four days.
He visited the emergency department (ED) last night due to increased difficulty in breathing.
The patient has a 20-year history of smoking half a pack of cigarettes per day and has no significant medical or surgical history.
The nurse has placed the patient on a cardiorespiratory monitor and administered a nasal cannula. After completing an assessment, the nurse documented the findings in the patient’s chart.
Which assessment findings indicate hypoxia?
Productive cough
Respiratory rate of 28 breaths/minute
Oxygen saturation of 90% on room air
Heart rate of 101 beats/minute
Capillary refill of 4 seconds
Blood pressure of 145/89 mm Hg
Correct Answer : B,C,D
Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale
A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Addiction refers to a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The intricate handwashing ritual that lasts two hours or more described by the client does not indicate substance use or dependency, which are common characteristics of addiction.
Choice B rationale
Compulsion refers to repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The client’s intricate handwashing ritual that lasts two hours or more and their concern about maintaining cleanliness align with the definition of a compulsion.
Choice C rationale
Obsession refers to recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and unwanted. While the client’s concern about maintaining cleanliness could potentially be seen as an obsession, the act of handwashing is a behavior, which aligns more with the definition of a compulsion.
Choice D rationale
Phobia refers to an extreme or irrational fear of or aversion to something. The client’s behavior does not indicate an extreme or irrational fear but rather a compulsion to maintain cleanliness through an intricate handwashing ritual.
Correct Answer is ["A","B","C","F"]
Explanation
Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale
Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.
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