A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?
Lethargy
Bradycardia
Intercostal retractions
Bradypnea
The Correct Answer is C
Intercostal retractions, or the inward movement of the chest wall between the ribs, are a sign of respiratory distress and hypoxia. They indicate increased work of breathing and reduced lung expansion, which are common in clients who have postoperative atelectasis. Atelectasis is a collapse of alveoli in a part of the lung, which impairs gas exchange and oxygenation.
a) Lethargy, or a state of reduced mental alertness and energy, is not a typical manifestation of hypoxia. It can be caused by other factors, such as pain, medication, infection, or electrolyte imbalance. Hypoxia usually causes restlessness, anxiety, or confusion.
b) Bradycardia, or a slow heart rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, vagal stimulation, or heart block. Hypoxia usually causes tachycardia, or a fast heart rate, as the body tries to compensate for the low oxygen level.
d) Bradypnea, or a slow respiratory rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, brain injury, or metabolic alkalosis. Hypoxia usually causes tachypnea, or a fast respiratory rate, as the body tries to increase oxygen intake and carbon dioxide elimination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Increased anteroposterior diameter of the chest, also known as barrel chest, is a common finding in clients who have COPD with emphysema. It is caused by chronic air trapping and hyperinflation of the lungs, which results in fattening of the diaphragm and widening of the rib cage.
a) Oxygen saturation level 96% is within the normal range of 95% to 100% and does not indicate hypoxemia or impaired gas exchange. Clients who have COPD with emphysema typically have lower oxygen saturation levels, ranging from 88% to 92%.
b) Respiratory alkalosis is a condition in which the blood pH is elevated due to decreased carbon dioxide levels. It is caused by hyperventilation, which can occur in response to hypoxia, anxiety, or pain. Clients who have COPD with emphysema usually have respiratory acidosis, which is a condition in which the blood pH is lowered due to increased carbon dioxide levels. It is caused by hypoventilation, which results from impaired lung function and airway obstruction.
d) Petechiae on chest are small red or purple spots on the skin caused by bleeding from capillaries. They are not a typical finding in clients who have COPD with emphysema, unless they have severe coughing episodes or coagulation disorders. They can indicate infection, inflammation, trauma, or vascular disease.
Correct Answer is A
Explanation
Answer: A
Rationale:
A) Administering a nebulized beta-adrenergic:
In the case of an acute asthma exacerbation, administering a nebulized beta-adrenergic agonist (such as albuterol) is the highest priority. These medications act quickly to relax bronchial smooth muscle, dilate airways, and improve airflow. This intervention directly addresses the underlying bronchospasm and helps to alleviate the acute symptoms of asthma.
B) Providing immediate rest for the client:
While rest is important in managing an acute asthma exacerbation, it is not the immediate priority. Addressing the airway obstruction with appropriate medications is crucial for stabilizing the client's condition before focusing on comfort measures such as rest.
C) Positioning the client in high-Fowler's:
Positioning the client in a high-Fowler's position can help improve lung expansion and facilitate breathing. However, this action is secondary to administering medication that can relieve the acute symptoms of bronchoconstriction. The medication should be administered first to rapidly address the exacerbation.
D) Initiating oxygen therapy:
Oxygen therapy might be necessary if the client shows signs of hypoxemia or severe respiratory distress. However, the immediate priority is to address the bronchospasm with a nebulized beta-adrenergic agonist to improve airflow. Once the acute bronchospasm is managed, oxygen therapy can be implemented if needed to support oxygen saturation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today