A nurse is assessing a client for early signs of hypoxemia during an asthma attack. Which manifestation should the nurse expect?

Hypotension

Nausea

Dysphagia

Confusion

Answer and Explanation

The Correct Answer is D

A: Hypotension is not an early sign of hypoxemia. It can occur in severe cases but is not typically an initial indicator.

B: Nausea is not a common sign of hypoxemia. It may occur due to other factors but is not directly related to low oxygen levels.

C: Dysphagia, or difficulty swallowing, is not a sign of hypoxemia. It is related to swallowing disorders rather than oxygen levels.

D: Confusion is an early sign of hypoxemia. Low oxygen levels can affect brain function, leading to confusion and other cognitive changes.

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Correct Answer is B

Explanation

A: The client attempting to remove the restraint does not necessarily indicate a need to loosen it. The nurse should assess the reason for the client’s behavior.

B: The client’s hand being cold and pale indicates compromised circulation, which requires immediate loosening of the restraint to restore blood flow.

C: Full range of motion in the wrist suggests that the restraint is not too tight and does not need to be loosened.

D: A capillary refill of less than 2 seconds indicates good circulation, so the restraint does not need to be loosened.

A. Assess characteristics of her sputum. B. Assess pulse and respirations. C. Instruct to slowly exhale with pursed lips. D. Auscultate lung fields.

Correct Answer is D

Explanation

A: Assessing the characteristics of the sputum is important for understanding the nature of the infection and the effectiveness of the treatment, but it is not the first action to take before the procedure.

B: Assessing pulse and respirations is the first action the nurse should take. This provides baseline data on the client’s respiratory and cardiovascular status, which is crucial for monitoring the client’s response to the procedure and ensuring safety.

C: Instructing the client to slowly exhale with pursed lips is a technique used to improve breathing efficiency and oxygenation, but it is not the first action to take before the procedure.

D: Auscultating lung fields is important for assessing the client’s respiratory status and identifying areas of congestion or decreased breath sounds, but it should follow the initial assessment of pulse and respirations.

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A nurse is assessing a client for early signs of hypoxemia during an asthma attack. Which manifestation should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse is assessing a client for early signs of hypoxemia during an asthma attack. Which manifestation should the nurse expect?