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 C

Explanation

A. Respiratory rate 20/min: A respiratory rate of 20/min is within the normal range for an adolescent. While respiratory function should always be monitored, this finding is not alarming in the context of blunt trauma.

B. Heart rate 72/min: A heart rate of 72/min is within the normal range for an adolescent. This does not indicate immediate concern, and the patient’s heart rate is stable.

C. Blood pressure 89/50 mm Hg: A blood pressure of 89/50 mm Hg is low and indicates potential shock, which is a life-threatening concern. Hypotension following blunt abdominal trauma can suggest internal bleeding or organ injury, which requires immediate intervention.

D. Abdominal pain rated 4 on a scale of 0 to 10: While abdominal pain is a concern, a pain level of 4/10 is not immediately life-threatening. The priority is addressing the low blood pressure, which could indicate shock or internal bleeding, requiring urgent medical attention.

A. The burned area is pink in color with blisters present. B. The burned area is red in color with eschar present C. The burned area is black in color and pain is absent. D. The burned area is yellow in color with severe edema.

Correct Answer is C

Explanation

A. The burned area is pink in color with blisters present: This is characteristic of a partial thickness (second-degree) burn, not a full-thickness burn. Blisters and pink or red coloring are typically seen in second-degree burns, which involve the epidermis and part of the dermis.

B. The burned area is red in color with eschar present: Red coloring with eschar is typically seen in a deep partial-thickness (second-degree). Full-thickness burns often present with eschar, but the color is usually waxy white, leathery, brown, or black.

C. The burned area is black in color and pain is absent: Full-thickness burns (third-degree) often appear black or charred. Pain is usually absent because the nerve endings in the affected area are destroyed and it involves all layers of the skin.

D. The burned area is yellow in color with severe edema: Yellow coloring and severe edema are more indicative of a superficial or partial-thickness burn. Full-thickness burn is more likely to be black and painless.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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