A nurse is assessing a client who has hypoxemia for a late sign. Which finding should the nurse expect?

Hypertension

Tachycardia

Pallor

Bradypnea

Answer and Explanation

The Correct Answer is C

A: Hypertension is not typically a late sign of hypoxemia. It can occur in various conditions but is not specific to hypoxemia.

B: Tachycardia is an early sign of hypoxemia as the body attempts to compensate for low oxygen levels by increasing the heart rate.

C: Pallor is a late sign of hypoxemia. It indicates poor oxygenation and perfusion, often seen when the body can no longer compensate for the lack of oxygen.

D: Bradypnea, or slow breathing, is not a typical sign of hypoxemia. Hypoxemia usually causes an increase in respiratory rate (tachypnea) as the body tries to take in more oxygen.

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Correct Answer is A

Explanation

A: Debriding the wound is the next step for a black (necrotic) pressure ulcer. Removing the dead tissue is essential to promote healing and prevent infection.

B: Managing drainage is important for wound care but is not the immediate next step for a necrotic ulcer.

C: Documenting the wound is necessary but does not address the need for debridement.

D: Monitoring the wound is important, but active intervention (debridement) is required for a necrotic ulcer to promote healing.

A. The client is attempting to remove the restraint. B. The client’s hand is cold and pale. C. The client has full range of motion in her wrist. D. The client has a capillary refill of less than 2 seconds.

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.

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A nurse is assessing a client who has hypoxemia for a late sign. Which finding should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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