A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action?

Atelectasis

Joint contractures

Pressure ulcers

Renal calculi

Answer and Explanation

The Correct Answer is B

A. Atelectasis is prevented primarily through deep breathing exercises and respiratory interventions, not passive ROM.
B. Passive ROM and splinting help prevent joint contractures by maintaining joint mobility and alignment, so the absence of contractures indicates successful prevention.
C. Pressure ulcers are avoided through regular repositioning and skin care rather than passive ROM alone.
D. Renal calculi are primarily prevented through hydration and diet, not passive ROM or splinting.

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Correct Answer is C

Explanation

A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.

A. Decrease in hemoglobin level B. Increase in diastolic filling time C. Increase in stroke volume D. Decrease in cardiac output

Correct Answer is D

Explanation

A. An increase in heart rate does not directly affect hemoglobin levels; this option is incorrect.
B. A higher heart rate decreases diastolic filling time, as there is less time for the heart to fill between beats, which can lead to reduced stroke volume.
C. An increased heart rate does not inherently increase stroke volume; in fact, at very high rates, stroke volume can decrease due to reduced filling time.
D. The significant increase in heart rate to 164 beats/min can lead to decreased cardiac output due to compromised diastolic filling and reduced stroke volume.

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A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

Correct Answer is C

Explanation

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect as a result?

Correct Answer is D

Explanation

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