A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

Bradypnea

Cyanosis

Pallor

Bradycardia

Answer and Explanation

The Correct Answer is B

A. Bradypnea, or abnormally slow breathing, is not typically associated with hypoxia. Hypoxia usually triggers an increase in respiratory rate (tachypnea) as the body attempts to take in more oxygen to meet its needs.
B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is a key sign of hypoxia. It occurs when there is insufficient oxygen in the blood, leading to a darker color of deoxygenated hemoglobin. Cyanosis is most commonly observed in the lips, fingertips, and toes.
C. Pallor, or paleness of the skin, can occur in various conditions but is not specific to hypoxia. It is more commonly associated with anemia or shock rather than low oxygen levels in the blood.
D. Bradycardia, or a slower-than-normal heart rate, is not typically a manifestation of hypoxia. Instead, hypoxia often causes tachycardia as the body attempts to increase oxygen delivery to tissues by pumping blood more quickly.

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Correct Answer is D

Explanation

A. The "Choice of Analgesia and Sedation" component of the ABCDEF assessment tool focuses on selecting appropriate pain relief and sedation strategies for the patient but does not directly relate to the weaning process.
B. "Assess, Prevent, and Manage Pain" involves ensuring the patient is comfortable and free from pain, which is important but not specifically related to weaning from the ventilator.
C. "Delirium: Assess, Prevent, and Manage" addresses the cognitive status of the patient, particularly the prevention and management of delirium, which is a critical aspect of care but not directly related to ventilator weaning.
D. "Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)" directly involves the weaning process, as it includes assessing the patient's ability to breathe independently by reducing or removing sedation (SAT) and evaluating their capacity for spontaneous breathing (SBT).

A. Provide mouth care. B. Cup hands and tap on the client's chest repeatedly. C. Auscultate lung fields. D. Position the client so that the lung area to be drained is above the client's trachea.

Correct Answer is D

Explanation

A. Provide mouth care: Mouth care is important for overall comfort and hygiene but is not the first step in preparing for chest percussion, vibration, and postural drainage. The priority is to prepare the client for the procedures that will aid in clearing lung secretions.

B. Cup hands and tap on the client's chest repeatedly: This action is part of chest percussion and should be performed after positioning the client correctly. Percussion should be done on the appropriate lung areas based on the positioning.

C. Auscultate lung fields: Auscultation of lung fields is essential for assessing lung sounds and determining the effectiveness of therapy. However, it should be done after positioning the client to ensure that the correct areas are being treated and assessed.

D. Position the client so that the lung area to be drained is above the client's trachea: Proper positioning is crucial for effective postural drainage, as it allows gravity to assist in moving secretions from the lung areas to the central airways. This should be done before performing chest percussion or vibration.

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A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with weaning a client from the ventilator. Which of the following parts of the ABCDEF assessment tool does the weaning process represent?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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