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

C. Ease the visitor to the floor: This is the first priority to prevent injury. Safely guiding the person to the ground helps reduce the risk of trauma from falling.

A. Maintain a patent airway: Once on the ground, the nurse should position the person (ideally on their side) to promote airway patency and prevent aspiration.

D. Obtain vital signs: After the seizure ends, assessing vital signs helps evaluate postictal status and detect any complications such as hypoxia or hypotension.

B. Record the seizure activity observed: Documentation of the seizure’s onset, duration, and characteristics is important, but it comes after safety and assessment priorities are addressed.

A. Defibrillation B. Airway management C. Amiodarone administration D. Epinephrine administration

Correct Answer is A

Explanation

A. Defibrillation: Ventricular fibrillation (VF) is a life-threatening arrhythmia that requires immediate defibrillation to restore normal rhythm. The priority action in a pulseless, unresponsive, and apneic client is to deliver a shock to stop the erratic electrical activity and allow the heart to re-establish a normal rhythm.

B. Airway management: While airway management is crucial for any unresponsive client, it is not the immediate priority in ventricular fibrillation. The first step is to treat the arrhythmia with defibrillation, as the absence of a pulse and irregular rhythm are more immediately life-threatening.

C. Amiodarone administration: Amiodarone may be administered after defibrillation attempts if VF persists. However, defibrillation is the first-line treatment. Amiodarone is considered once initial resuscitation efforts are underway and if the rhythm does not convert.

D. Epinephrine administration: Epinephrine can be administered after defibrillation if needed. However, defibrillation remains the priority intervention for ventricular fibrillation. Epinephrine is usually given after the first shock and subsequent CPR.

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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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Naxlex Comprehensive Predictor Exams

The nurse sees a visitor walking in the hallway begin to have a seizure. The nurse should do which of the following in priority order? A. Maintain a patent airway. B. Record the seizure activity observed. C. Ease the visitor to the floor. D. Obtain vital signs.

Correct Answer is B

Explanation

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

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