A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?
Bradypnea
Restlessness
Hypertension
Tachycardia
The Correct Answer is D
A. Bradypnea: Bradypnea (slow breathing) is not a typical late sign of hypoxia. Instead, clients with worsening hypoxia often develop tachypnea (rapid breathing) as the body tries to compensate for low oxygen levels.
B. Restlessness: Restlessness is an early sign of hypoxia, not a late one. It occurs due to inadequate oxygenation of the brain, leading to agitation and confusion.
C. Hypertension: Hypertension can be an early response to hypoxia as the body attempts to increase oxygen delivery. However, as hypoxia progresses, blood pressure may drop due to worsening oxygen deprivation.
D. Tachycardia: Tachycardia (increased heart rate) is a late sign of hypoxia. The heart compensates for low oxygen levels by increasing cardiac output. However, if untreated, hypoxia can progress to bradycardia and cardiac arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.
B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.
C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.
D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.
Correct Answer is ["A","B","E","F"]
Explanation
Oxygen Saturation: 84% on 3L nasal cannula
- The client’s oxygen saturation has dropped from 89% to 84%, indicating worsening hypoxia. In an asthma exacerbation, declining oxygen levels suggest inadequate gas exchange and potential progression to respiratory failure.
Mucous Membranes Cyanotic
- Cyanosis is a late sign of hypoxia and indicates that the client is not oxygenating adequately. This suggests that bronchoconstriction and airway obstruction are worsening despite initial treatment.
Respiratory Rate: 27/min (Increased from 22/min)
- An increasing respiratory rate suggests increased work of breathing. The client is attempting to compensate for worsening airway obstruction, which can lead to respiratory fatigue if not managed promptly.
Client Appears Anxious
- Anxiety in this context may indicate air hunger and respiratory distress. Clients in worsening asthma exacerbations often become restless or agitated due to inadequate oxygenation.
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