The nurse is caring for a patient admitted to the hospital with alterations in oxygenation.
The nurse understands that which of the following are common clinical manifestations in patients with alterations in oxygenation? Select all that apply.

Hypotension.

Cyanosis.

Hypoxia.

Bradycardia.

Moist mucous membranes.

Answer and Explanation

Correct Answer : B,C

Choice A rationale

Hypotension, while a possible consequence of severe oxygenation alterations, is not a primary or direct clinical manifestation. It often results from the systemic effects of prolonged hypoxemia, such as myocardial depression or severe acidosis leading to vasodilation. The initial physiological response to hypoxemia is typically tachycardia and hypertension as a compensatory mechanism to increase oxygen delivery, with hypotension occurring later as a sign of decompensation.

Choice B rationale

Cyanosis is a direct clinical manifestation resulting from a high concentration of deoxygenated hemoglobin in the blood. It becomes visible when the deoxygenated hemoglobin level exceeds 5 g/dL. Central cyanosis, seen in the lips and mucous membranes, indicates systemic hypoxemia, while peripheral cyanosis, in the extremities, suggests local impaired circulation or vasoconstriction. It is a key sign of inadequate oxygenation.

Choice C rationale

Hypoxia, defined as a deficiency in the amount of oxygen reaching the tissues, is a fundamental alteration in oxygenation. While not a visible sign, it is the underlying pathological condition that drives other clinical manifestations. The body's cells and organs require a constant supply of oxygen for aerobic metabolism. When this supply is insufficient, cellular function is impaired, leading to the clinical signs and symptoms.

Choice D rationale

Bradycardia is generally not a common initial manifestation of altered oxygenation. The body's primary compensatory mechanism for hypoxemia is to increase heart rate and cardiac output to enhance oxygen delivery, leading to tachycardia. Bradycardia may occur as a late, ominous sign of severe, prolonged, and decompensated hypoxia, particularly in infants and children, and often precedes cardiac arrest.

Choice E rationale

Moist mucous membranes are a sign of adequate hydration and perfusion. In patients with significant alterations in oxygenation, especially in conditions leading to mouth breathing or tachypnea, mucous membranes are more likely to become dry due to increased insensible water loss. Therefore, moist mucous membranes are not a common clinical manifestation of impaired oxygenation. *.

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Correct Answer is D

Explanation

Choice A rationale

Flail chest is the paradoxical movement of a section of the chest wall, caused by multiple rib fractures in two or more places. It is characterized by paradoxical chest wall motion, where the injured segment moves in during inspiration and out during expiration. While it is a severe chest injury, it does not typically involve a large accumulation of blood in the pleural space, which is the defining characteristic mentioned in the patient's presentation.

Choice B rationale

A tension pneumothorax is a life-threatening condition where air enters the pleural space but cannot exit, causing a rapid increase in intrathoracic pressure. This leads to tracheal deviation, hypotension, and profound respiratory distress. While it can cause a collapsed lung and dyspnea, the defining characteristic is air trapping, not blood accumulation in the pleural space, making this diagnosis inconsistent with the patient's specific presentation of hemothorax.

Choice C rationale

A simple pneumothorax is the presence of air in the pleural space, causing the lung to collapse, but without the one-way valve effect seen in a tension pneumothorax. It presents with dyspnea and asymmetrical chest expansion. While it causes a collapsed lung, the defining feature of this patient's case is the presence of a blood accumulation in the pleural space, which is not a hallmark of a simple pneumothorax.

Choice D rationale

A hemothorax is a medical condition characterized by the accumulation of blood in the pleural cavity, which is the space between the lungs and the chest wall. The presence of a collapsed lung, blood accumulation in the pleural space, dyspnea, and asymmetrical chest expansion directly corresponds to the classic presentation of a hemothorax. This diagnosis accurately and completely accounts for all the symptoms described in the patient's clinical scenario. .

A. Request a prescription for an antitussive medication. B. Provide small quantities of ice chips and sips of water. C. Ask the respiratory therapist to provide humidified air. D. Apply oxygen and continuous pulse oximetry.

Correct Answer is D

Explanation

Choice A rationale

A loud, brassy cough in a burn patient rescued from a fire is a critical sign of upper airway edema, often caused by inhalation of hot gases or toxins. This swelling can rapidly lead to complete airway obstruction. Antitussive medications suppress coughing and would mask this vital clinical sign, delaying the necessary and immediate intervention of securing the airway.

Choice B rationale

Providing ice chips or sips of water may be considered for a sore throat, but in the context of a potential inhalation injury, this action is contraindicated. Swelling of the laryngeal and pharyngeal tissues can progress rapidly, and there is a high risk of aspiration if the patient's swallowing reflex is compromised or the airway becomes obstructed.

Choice C rationale

Humidified air can help soothe irritated mucous membranes, but it is not the first action in a patient with a rapidly deteriorating airway. The loud, brassy cough signifies significant laryngeal edema, which can progress to complete obstruction. The immediate priority is to assess, stabilize, and protect the airway with supplemental oxygen and continuous monitoring before it closes.

Choice D rationale

A loud, brassy cough is a hallmark sign of upper airway edema, a serious complication of inhalation injury. The swelling can quickly lead to airway obstruction. Applying oxygen and continuous pulse oximetry is the first action to ensure adequate oxygenation and monitor for signs of impending respiratory failure, while simultaneously preparing for definitive airway management.

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The nurse is caring for a patient admitted to the hospital with alterations in oxygenation. The nurse understands that which of the following are common clinical manifestations in patients with alterations in oxygenation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient in the emergency department has dyspnea, asymmetrical chest expansion, and an oxygen saturation of 90%. A chest X-ray shows a collapsed lung and blood accumulation in the pleural space. What is the correct diagnosis?

Correct Answer is D

Explanation

An emergency room nurse assesses a patient who was rescued from a home fire. The patient suddenly develops a loud, brassy cough. What action would the nurse take first?

Correct Answer is D

Explanation

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The nurse is caring for a patient admitted to the hospital with alterations in oxygenation.
The nurse understands that which of the following are common clinical manifestations in patients with alterations in oxygenation? Select all that apply.