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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
To calculate the total intravenous fluids infused in 24 hours for a burn client, use the Parkland formula.
- Calculate Fluid Resuscitation Volume (Parkland Formula)
Convert client's weight from pounds (lb) to kilograms (kg).
Client weight = 147.4 lb / 2.2 lb/kg
= 67 kg.
- Calculate the total fluid volume needed for the first 24 hours using the Parkland formula.
Parkland Formula = 4 mL × client weight (kg) × % TBSA burned
Total fluid volume (24 hrs) = 4 mL × 67 kg × 31.5%
= 8442 mL.
- Calculate Insulin Infusion Volume in 24 hours
Concentration of the insulin solution = 100 units / 100 mL
= 1 unit/mL.
- Calculate the volume of insulin solution infused per hour.
Infusion rate = 5 units/hr
Volume infused per hour (mL/hr) = Desired units/hr / Concentration (units/mL)
= 5 units/hr / 1 unit/mL
= 5 mL/hr.
- Calculate the total volume of insulin solution infused in 24 hours.
Total insulin volume (24 hrs) = Volume infused per hour (mL/hr) × 24 hours
= 5 mL/hr × 24 hours
= 120 mL.
- Calculate Total Intravenous Fluids Infused in 24 hours
Total IV fluids = Total fluid resuscitation volume + Total insulin volume
= 8442 mL + 120 mL Total IV fluids
= 8562 mL.
Correct Answer is ["0.8"]
Explanation
Desired dose = 3,800 units.
Available concentration = 5,000 units/mL.
- Calculate the volume to administer.
Volume (mL) = Desired dose (units) / Available concentration (units/mL)
= 3,800 units / 5,000 units/mL
= 0.76 mL.
- Round the answer to the nearest tenth.
= 0.8 mL.
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