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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Joint contractures: Joint contractures are a common manifestation of systemic scleroderma, but they are not directly related to altered tissue perfusion. They are more related to skin and tissue fibrosis.
B. Peripheral arterial dilation: Peripheral arterial dilation is not typically associated with systemic scleroderma. Instead, peripheral vasoconstriction, such as in Raynaud's phenomenon, is more common.
C. Raynaud's phenomenon: Raynaud's phenomenon, characterized by episodic vasospasm of small arteries in response to cold or stress, can lead to impaired tissue perfusion, especially in the extremities.
D. Pulmonary fibrosis: Pulmonary fibrosis is a complication of systemic scleroderma that affects lung tissue, but it is not directly related to altered tissue perfusion. It may lead to impaired gas exchange rather than altered perfusion.
Correct Answer is D
Explanation
A. Freshly squeezed orange juice: Orange juice is generally not considered a trigger for gout attacks. However, it is high in fructose, which may contribute to gout if consumed excessively.
B. Milk: Milk is not typically associated with triggering gout attacks and is often recommended as part of a healthy diet for gout.
C. Black Coffee: Coffee, especially black coffee, is generally considered safe for individuals with gout and may even have some protective effects against gout attacks.
D. Sweetened iced tea: Sweetened iced tea is often made with high-fructose corn syrup, which can increase uric acid levels and potentially trigger gout attacks. Therefore, it is important for individuals with gout to limit their intake of sweetened beverages like iced tea.
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