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 B

Explanation

A: Obtaining a chest x-ray is important for diagnosing potential complications but is not the immediate first action to improve oxygen saturation.

B: Raising the head of the bed helps improve lung expansion and oxygenation. It is a quick and effective first step to increase oxygen saturation.

C: Administering a prescribed analgesic can help with pain management but does not directly address the low oxygen saturation.

D: Administering oxygen at 2 L/min is important but should follow the initial step of raising the head of the bed to optimize breathing.

A. Check the display on the PCA pump. B. Obtain an order for another pain medication for breakthrough pain. C. Administer a bolus of medication. D. Encourage the client to administer a demand dose.

Correct Answer is A

Explanation

A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.

B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.

C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.

D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.

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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

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