A nurse suspects impending respiratory failure in a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse should recognize that which assessment finding supports the presence of hypoxemia?
The client has circumoral cyanosis.
The client's heart rate is 86 bpm.
The client has a pulse ox of 90% on room air.
The client is lethargic.
The Correct Answer is C
A. The client has circumoral cyanosis: Circumoral cyanosis, or bluish discoloration around the mouth, is a sign of hypoxia but may not be present in all cases of hypoxemia. Pulse oximetry provides a more objective measurement.
B. The client's heart rate is 86 bpm: Heart rate may be within normal limits even in the presence of hypoxemia, as compensatory mechanisms may not be fully activated.
C. The client has a pulse ox of 90% on room air: A pulse oximetry reading of 90% indicates hypoxemia (oxygen saturation below normal levels), which is a significant finding, especially in a client with COPD who may already have compromised respiratory function.
D. The client is lethargic: Lethargy may occur with severe hypoxemia, but it is a late sign and may not always be present. Monitoring oxygen saturation is more reliable for early detection of hypoxemia.
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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Pneumocystis pneumonia (PCP) is a common opportunistic infection in individuals with AIDS, particularly when their CD4 T-cell count falls below 200/mm3. PCP is caused by the fungus Pneumocystis jirovecii and is a significant cause of morbidity and mortality in AIDS patients. The CD4 T-cell count is a key indicator of immune function in HIV/AIDS patients. A CD4 T-cell count below 200/mm3 is indicative of severe immune suppression and significantly increases the risk of opportunistic infections such as pneumocystis pneumonia.
Correct Answer is A
Explanation
A. Hypokalemia: Furosemide is a loop diuretic that works by increasing urinary excretion of sodium, chloride, and water, which can lead to potassium loss. Hypokalemia is a common electrolyte imbalance associated with the use of loop diuretics like furosemide. Potassium depletion can cause various complications, including cardiac dysrhythmias, muscle weakness, and fatigue.
B. Hypocalcemia: Furosemide does not directly affect calcium levels, so hypocalcemia is not a common electrolyte imbalance associated with its use.
C. Hypernatremia: Furosemide promotes the excretion of sodium, so hypernatremia (elevated serum sodium levels) is not typically a concern with its use.
D. Hyperkalemia: Furosemide can cause potassium loss, so hyperkalemia is not a risk associated with its use.
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