Exhibits here

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia.

Answer and Explanation

The Correct Answer is []

Cardiovascular

- Capillary refill 4 seconds

- A prolonged capillary refill time indicates poor peripheral perfusion, which can be a sign of hypoxia. Hypoxia can lead to reduced oxygen delivery to the tissues, resulting in delayed capillary refill.

Respiratory

- Oxygen saturation 90% on room air

- An oxygen saturation level of 90% is below the normal range (95-100%) and indicates that the blood is not adequately oxygenated, which is a direct sign of hypoxia.

- Respiratory rate 28 breaths/minute

- An elevated respiratory rate (tachypnea) is a common compensatory mechanism in response to hypoxia. The body attempts to increase oxygen intake and carbon dioxide expulsion by breathing more rapidly.

Neurological

- Anxious

- Anxiety can be a symptom of hypoxia. When the brain and other vital organs do not receive enough oxygen, it can trigger a sense of anxiety and restlessness as part of the body's alarm system.

- Restless

- Restlessness is another common symptom of hypoxia. It occurs because the body is trying to compensate for the lack of oxygen, leading to increased agitation and an inability to remain
calm.

Rationales for the Incorrect Choices:

- Cardiovascular

- Heart rate 101 beats/minute: While an elevated heart rate can be a compensatory response to hypoxia, it alone does not directly indicate hypoxia.
- Blood pressure 145/89 mm Hg: Elevated blood pressure is not a direct indicator of hypoxia and can be influenced by various factors including anxiety and pain.

- Respiratory

- Productive cough: A productive cough suggests respiratory infection or inflammation but does not directly measure oxygenation status or indicate hypoxia.

- Neurological

- Awake and alert: Being awake and alert indicates normal mental status and does not suggest hypoxia. Hypoxia typically affects cognitive function, leading to confusion or decreased level of consciousness in more severe cases.

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Correct Answer is D

Explanation

A. Wearing gloves when interviewing the client. This behavior may make the client feel stigmatized or rejected, as it could imply that the nurse perceives them as contagious or untouchable.
B. Allowing the client to ventilate feelings. While this is important for emotional support, it does not directly address the psychosocial need for acceptance.
C. Encouraging the client to join a support group. This can help the client feel less isolated and gain support from others with similar experiences, but it is not as immediate or direct as personal interaction.
D. Shaking the client's hand during an introduction. This gesture of physical contact can significantly convey acceptance and normalcy, helping the client feel respected and accepted despite their condition.

A. Digoxin. B. Hydrochlorothiazide. C. Nadolol. D. Captopril.

Correct Answer is C

Explanation

A. Digoxin.
Digoxin is a cardiac glycoside that helps increase the force of myocardial contraction and is generally used to treat heart failure. It does not typically pose a significant risk for cardiogenic shock.

B. Hydrochlorothiazide.
Hydrochlorothiazide is a diuretic used to manage fluid retention in heart failure. It can cause electrolyte imbalances but is not directly linked to causing cardiogenic shock.

C. Nadolol.
Nadolol is a beta-blocker, which can reduce the heart rate and the strength of heart contractions. In a client with severe heart failure, excessive beta-blockade can lead to a significant decrease in cardiac output, increasing the risk for cardiogenic shock.

D. Captopril.
Captopril is an ACE inhibitor that helps manage heart failure by reducing afterload and preload.
While it can cause hypotension, it is not typically associated with a direct risk of cardiogenic shock.

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Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.

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Exhibits here

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia.