A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?

Cyanosis

Bradypnea

Hypertension

Peripheral edema

Answer and Explanation

The Correct Answer is C

A. Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late sign of hypoxia and indicates significant oxygen deprivation.

B. Bradypnea (abnormally slow breathing) is not typically an early sign; in early hypoxia, the respiratory rate usually increases as the body attempts to compensate.

C. Hypertension can occur in early hypoxia as the body responds to reduced oxygen levels by increasing cardiac output and systemic vascular resistance. Other early signs may include tachypnea, restlessness, anxiety, and increased heart rate.

D. Peripheral edema is not a direct indication of hypoxia; it is more associated with fluid retention or heart failure rather than early oxygen deprivation.

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Correct Answer is A

Explanation

A. Guiding the client away from background noise improves the ability to hear and understand spoken instructions, as hearing deficits are often exacerbated by environmental noise. This action supports effective communication and client comprehension.

B. Standing next to the client is less effective; the nurse should face the client directly so that lip movements and facial expressions are visible, which aids understanding.

C. Repeating misunderstood phrases may help, but without addressing environmental factors such as noise, communication may still be impaired.

D. Providing instructions in Braille is appropriate for clients with visual impairments, not hearing deficits.

A. Locking the brakes on the wheelchair. B. Positioning the wheelchair close to the bed. C. Using a gait belt. D. Ensuring the patient is wearing non-slip footwear.

Correct Answer is C

Explanation

A. Locking the brakes on the wheelchair is important to prevent movement, but it does not directly provide support to the patient during the transfer.

B. Positioning the wheelchair close to the bed reduces the distance of the transfer but does not ensure stability or safety during movement.

C. Using a gait belt is the most crucial intervention, as it provides a secure point of contact for the nurse to support and stabilize the patient, reducing the risk of falls or injury during the transfer.

D. Ensuring the patient wears non-slip footwear helps prevent slipping, but it is secondary to the physical support provided by a gait belt during the actual transfer.

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A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?

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