The nurse is caring for a client with hypoxia. Which finding should be the most concerning to the nurse?

Peripheral neuropathy

Pursed-lip breathing

Delayed capillary refill

Central cyanosis

Answer and Explanation

The Correct Answer is D

Rationale:
A. Peripheral neuropathy is a chronic condition often related to diabetes or nerve damage. While it may be associated with hypoxia in some cases, it is not an acute or immediate indicator of oxygen deprivation.

B. Pursed-lip breathing is a compensatory mechanism used by clients with respiratory distress or chronic lung disease to improve ventilation. It indicates the body is attempting to manage hypoxia but is not an emergency sign on its own.

C. Delayed capillary refill suggests poor peripheral perfusion, which can be concerning, but it reflects a localized or early sign of compromised circulation rather than severe hypoxia.

D. Central cyanosis is the most concerning finding. It indicates that oxygen saturation in the arterial blood is critically low, affecting vital organs. The presence of blue discoloration in the lips, tongue, or mucous membranes reflects significant hypoxemia and requires immediate assessment and intervention, such as oxygen therapy and evaluation of the underlying cause.

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Correct Answer is B

Explanation

Rationale:
A. Stopping the enteral feedings and calling the healthcare provider is appropriate. The client is showing signs of possible aspiration or fluid overload—tachypnea, hypoxia, and bilateral crackles—which require immediate intervention to prevent further complications.

B. Lowering the head of the bed is contraindicated. A supine or low position increases the risk of aspiration, especially in a client receiving enteral feedings. Keeping the head elevated helps prevent gastric contents from entering the lungs and worsening respiratory compromise.

C. Administering oxygen via nasal cannula is appropriate to address hypoxia and improve oxygen saturation. Oxygen therapy is a supportive measure while further evaluation and interventions are initiated.

D. Placing the client in high Fowler’s position is correct. Elevating the head of the bed to 60–90 degrees helps reduce the risk of aspiration, improves lung expansion, and facilitates safer administration of enteral nutrition.

A. Reassure the client that the pain will stop after passing the stool. B. Insert the lubricated enema tubing 5-6 inches into the rectum. C. Position the client to left side-lying with the right knee flexed. D. Hang the soapsuds enema bag 22-28 inches above the mattress.

Correct Answer is C

Explanation

Rationale:
A. Reassuring the client that pain will stop after passing stool is supportive, but it does not ensure safety during the enema procedure. Pain may occur from distention or irritation, and safety measures must be in place to prevent injury.

B. Inserting the lubricated enema tubing 5–6 inches into the rectum is excessive for an adult. The recommended insertion depth for an adult is 3–4 inches. Inserting the tube too far can cause rectal trauma or perforation, making this action unsafe.

C. Positioning the client on the left side-lying with the right knee flexed (Sims’ position) is correct. This position allows gravity to assist the flow of the enema solution into the sigmoid colon and rectum, reduces the risk of injury, and improves comfort. Proper positioning is essential for safe and effective administration.

D. Hanging the soapsuds enema bag 22–28 inches above the mattress is unsafe. The recommended height is 12–18 inches above the rectum to prevent excessive flow rate, which can cause cramping, discomfort, or injury to the rectal mucosa. Hanging the bag too high increases the risk of trauma and rapid expulsion of the solution.

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The nurse is caring for a client with hypoxia. Which finding should be the most concerning to the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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