A nurse is assessing a client who is in the early stages of hypoxia. Which of the following assessment findings should the nurse expect?

Tachycardia

Bradypnea

Somnolence

Pallor

Answer and Explanation

The Correct Answer is A

A. Tachycardia: In the early stages of hypoxia, the body compensates for low oxygen levels by increasing the heart rate (tachycardia) to improve oxygen delivery to tissues. Tachycardia is one of the first signs of hypoxia as the cardiovascular system tries to compensate.

B. Bradypnea: Bradypnea, or slow breathing, is not typically seen in early hypoxia. Instead, hypoxia usually causes tachypnea (rapid breathing) as the body attempts to increase oxygen intake. Bradypnea is more likely to occur in severe hypoxia or respiratory failure.

C. Somnolence: Somnolence (drowsiness) may occur as hypoxia worsens, but it is not typically an early sign. In the early stages of hypoxia, the body compensates by increasing the heart rate and breathing rate, rather than causing drowsiness.

D. Pallor: Pallor can occur in hypoxia due to reduced oxygenation of the skin, but it is not one of the earliest signs. Tachycardia and increased respiratory rate are more common initial responses to hypoxia. Pallor tends to be seen as hypoxia progresses.

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Correct Answer is B

Explanation

A. Metabolic acidosis: Metabolic acidosis typically results from a condition like renal failure or diabetic ketoacidosis, where there is a decrease in bicarbonate or an increase in acid. Shallow and slow respirations are more indicative of respiratory acidosis.

B. Respiratory acidosis: Shallow and slow respirations (9/min) reduce the effectiveness of ventilation, leading to the accumulation of carbon dioxide (CO2) in the blood. The increased CO2 leads to a decrease in pH, causing respiratory acidosis.

C. Respiratory alkalosis: Respiratory alkalosis occurs when there is rapid or deep breathing, leading to excessive exhalation of CO2. Since the client has shallow and slow respirations, they are more at risk for respiratory acidosis, not alkalosis.

D. Metabolic alkalosis: Metabolic alkalosis is caused by conditions such as vomiting or excessive use of diuretics, which lead to an increase in bicarbonate. It is not typically associated with slow, shallow respirations.

A. Inspect the mouth for signs of inhalation injuries B. Administer intravenous pain medication C. Insert an indwelling urinary catheter D. Draw blood for a complete blood cell (CBC) count

Correct Answer is A

Explanation

A. Inspect the mouth for signs of inhalation injuries: The priority action for a client with burns, especially facial burns is to assess for potential inhalation injuries. Inhalation of hot gases or smoke can cause damage to the airways, leading to swelling, obstruction, and respiratory distress.

B. Administer intravenous pain medication: Pain management is important, but it is not the immediate priority. Ensuring the client’s airway is protected and that there are no life-threatening respiratory complications takes precedence over pain relief in the early stages of burn care.

C. Insert an indwelling urinary catheter: Inserting a urinary catheter is typically done for monitoring urine output in burn patients, especially if there is concern for fluid resuscitation needs. However, it is not the priority. Assessing for respiratory injury should come first.

D. Draw blood for a complete blood cell (CBC) count: While a CBC can provide useful information, such as signs of infection or anemia, it is not the priority action. The immediate priority is ensuring the airway is safe and free of inhalation injury, as respiratory compromise can lead to rapid deterioration.

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A nurse is assessing a client who is in the early stages of hypoxia. Which of the following assessment findings should the nurse expect?

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