Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assessing a patient and notes that the patient is experiencing hypoxia.
Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

increased respiratory rate

confusion

cyanosis

restlessness

dyspnea

Bradychardia

Hypertension

Nausea and vomiting

Answer and Explanation

Correct Answer : A,B,C,D,E

The correct answer is choices A, B, C, D, and E.

Hypoxia occurs when there is inadequate oxygen supply to the body's tissues. Signs of hypoxia can vary depending on the severity of the condition. The following signs can indicate hypoxia:

Increased respiratory rate - Hypoxia can cause an increased respiratory rate as the body tries to increase oxygen levels in the blood.
Confusion - Hypoxia can affect cognitive function, leading to confusion.
Cyanosis - Hypoxia can cause a blue or purple discoloration of the skin, lips, or nail beds due to the lack of oxygen.
Restlessness - Hypoxia can cause restlessness or agitation.
Dyspnea - Hypoxia can cause difficulty breathing, also known as dyspnea.
Bradycardia - Bradycardia, or a slow heart rate, is not typically a direct sign of hypoxia. Hypoxia often leads to tachycardia (increased heart rate) as the body tries to compensate for low oxygen levels.
Hypotension - While severe hypoxia can eventually lead to changes in blood pressure, hypotension (low blood pressure) is not a primary sign of hypoxia. Typically, hypoxia might cause hypertension or have no immediate impact on blood pressure.
Nausea and Vomiting - While nausea and vomiting can be related to various conditions, they are not specific signs of hypoxia. These symptoms might occur due to other issues or as a secondary effect in some cases, but they are not primary indicators of hypoxia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Apply restraints to the hands or wrists to keep the patient in bed:Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.

B. Place a belt restraint on the client when they are sitting in a chair:Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.

C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.

D. Educate the patient on using the call light and make sure the call light is within reach.This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.

A. Serosanguineous B. Sanguinous C. Purulent D. Serous

Correct Answer is B

Explanation

The correct answer is B. Sanguinous. Sanguinous drainage is bright red, indicating fresh bleeding, and may be seen in the first few hours after surgery. Dark red drainage may indicate that there is an increase in bleeding, and the nurse should notify the provider immediately. Serosanguineous drainage is pink in color and consists of both blood and serum. Purulent drainage is thick, yellow or green in color and consists of pus, indicating an infection. Serous drainage is clear or light yellow in color and contains serum without red blood cells.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a patient and notes that the patient is experiencing hypoxia. Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Correct Answer is D

Explanation

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is dark red in color. The nurse documents the drainage as which of the following?

Correct Answer is B

Explanation

For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

A nurse is assessing a patient and notes that the patient is experiencing hypoxia. Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

A nurse is interviewing a newly admitted patient. What question would best exhibit cultural competence?

A nurse is assessing a patient and notes that the patient is experiencing hypoxia.
Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.