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 "{\"xRanges\":[104.2578125,134.2578125],\"yRanges\":[114.30078125,144.30078125]}"
Explanation
Correct Answer is C
Explanation
A. A diet high in potassium: A high-potassium diet can actually help lower blood pressure and is often recommended for hypertensive patients.
B. Taking benazepril: Benazepril is an ACE inhibitor used to treat hypertension, so it is not a risk factor for developing high blood pressure.
C. Obstructive sleep apnea (OSA): OSA is a significant risk factor for the development of hypertension. The repeated episodes of apnea during sleep can lead to increased sympathetic nervous system activity and elevated blood pressure.
D. High-density lipoprotein (HDL) level of 70 mg/dL: A high HDL level is generally considered protective against cardiovascular diseases, including hypertension.
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