On arrival at the intensive care unit, a critically ill patient suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the patient’s arterial oxygen saturation (SaO₂) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

Tachycardia

Hypotension

Tachypnea

Fever

Answer and Explanation

The Correct Answer is B

Choice A: Tachycardia

Tachycardia, defined as a heart rate exceeding 100 beats per minute, can affect the accuracy of pulse oximetry readings. When the heart beats too quickly, it may not fill with enough blood between beats, leading to reduced perfusion and oxygen delivery to tissues. However, while tachycardia can influence the readings, it is not the most significant factor compared to hypotension.

Choice B: Hypotension

Hypotension, or low blood pressure, significantly impacts pulse oximetry accuracy. When blood pressure is low, there is reduced perfusion to peripheral tissues, including the extremities where pulse oximeters are typically placed. This reduced perfusion can lead to inaccurate readings, as the device may not detect sufficient blood flow to measure oxygen saturation accurately. Hypotension is a critical factor that can alter pulse oximetry values, making it the most relevant choice.

Choice C: Tachypnea

Tachypnea, or rapid breathing, can affect oxygen levels in the blood but does not directly interfere with the pulse oximeter’s ability to measure oxygen saturation. While it indicates respiratory distress and can lead to hypoxemia, the pulse oximeter can still provide accurate readings unless accompanied by other factors like low perfusion.

Choice D: Fever

Fever can cause peripheral vasodilation, which might theoretically affect pulse oximetry readings by altering blood flow to the extremities. However, this effect is generally minimal compared to the impact of hypotension. Fever alone is unlikely to cause significant inaccuracies in pulse oximetry measurements.

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Free Nursing Study Resources

Correct Answer is ["B","C","E","F"]

Explanation

Choice A Reason:

Weight gain is not typically associated with tuberculosis (TB). In fact, weight loss is a common symptom of TB due to the chronic nature of the infection and the body’s increased metabolic demands to fight the disease. Patients with TB often experience a loss of appetite and significant weight loss as the disease progresses.

Choice B Reason:

Low-grade fever is a common symptom of TB. The body’s immune response to the infection often results in a persistent low-grade fever, which can be one of the early signs of the disease. This fever is usually accompanied by other systemic symptoms such as night sweats and fatigue.

Choice C Reason:

Dyspnea, or difficulty breathing, can occur in patients with TB, especially if the infection has caused significant lung damage or if there is a large amount of fluid in the pleural space (pleural effusion). Dyspnea is a concerning symptom that indicates the need for further evaluation and treatment.

Choice D Reason:

Contusion, or bruising, is not a symptom associated with TB. TB primarily affects the lungs and can cause systemic symptoms, but it does not typically cause bruising. Contusions are more commonly associated with trauma or conditions that affect blood clotting.

Choice E Reason:

Lethargy, or a general sense of fatigue and weakness, is a common symptom of TB. The chronic nature of the infection and the body’s ongoing immune response can lead to significant fatigue. Patients with TB often feel tired and may have difficulty performing daily activities.

Choice F Reason:

Night sweats are a hallmark symptom of TB. Patients often experience drenching night sweats that can be quite severe. This symptom, along with fever and weight loss, is part of the classic triad of TB symptoms and is an important indicator for healthcare providers to consider TB in the differential diagnosis.

A. Muscle spasms B. Mood and affect C. Appetite D. Sleep pattern

Correct Answer is A

Explanation

Choice A reason:

Baclofen is primarily used to treat muscle symptoms caused by multiple sclerosis, including muscle spasms, stiffness, and pain1. It acts on the spinal cord nerves to decrease the number and severity of muscle spasms, thereby improving muscle movement2. The effectiveness of baclofen in managing multiple sclerosis symptoms is best evaluated by assessing the reduction in muscle spasms.

Choice B reason:

While mood and affect are important aspects of a patient’s overall well-being, they are not the primary indicators of baclofen’s effectiveness. Baclofen does not have a direct impact on mood and affect, as its main function is to relieve muscle spasms and improve muscle movement.

Choice C reason:

Appetite is not a primary concern when evaluating the effectiveness of baclofen. This medication is not known to significantly affect appetite. The main therapeutic goal of baclofen is to reduce muscle spasms and improve mobility in patients with multiple sclerosis.

Choice D reason:

Sleep pattern, although important for overall health, is not the primary measure of baclofen’s effectiveness. Baclofen’s primary role is to alleviate muscle spasms and improve muscle function. While it may have some impact on sleep due to its muscle-relaxing properties, this is not the main criterion for evaluating its effectiveness.

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Naxlex Comprehensive Predictor Exams

Which sign or symptom would the nurse anticipate in a patient diagnosed with tuberculosis? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["B","C","E","F"]

Explanation

A client is receiving baclofen for the management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?

Correct Answer is A

Explanation

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

A client with chronic lung disease is prescribed 40% oxygen via face mask. Which finding indicates to the nurse that the client is experiencing oxygen toxicity? Select all that apply.

The nurse is caring for a client with a heart rate of 143 beats/min with atrial fibrillation. Which assessment data will the nurse anticipate? Select all that apply:

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

What does the nurse recognize as clinical manifestations consistent with ascites? Select all that apply.

The nurse is planning health teaching for a client starting on donepezil for Alzheimer’s disease (AD). For which side effect will the nurse teach the family to monitor?