The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

Elevated blood pressure

Increased pulse rate

Cyanosis

Restlessness

Answer and Explanation

The Correct Answer is C

A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.

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Correct Answer is A

Explanation

A. Hyperkalemia can lead to dangerous cardiac arrhythmias and other heart-related complications due to its effect on the electrical conduction system of the heart, making cardiac assessment the priority.
B. While neurological assessment is important in various conditions, it is secondary to assessing cardiac status in hyperkalemia.
C. Gastrointestinal symptoms can occur with hyperkalemia, but they do not pose an immediate life-threatening risk like cardiac issues do.
D. Respiratory assessment is essential in many contexts, but the immediate threat of hyperkalemia lies in its impact on heart function, making cardiac assessment the most critical.

A. Assume that both have the same spiritual beliefs. B. Skip the spiritual belief assessment. C. Must use a formal assessment tool to determine patient's beliefs. D. Do not impose personal values on the patient.

Correct Answer is D

Explanation

A. Assuming that both have the same spiritual beliefs can lead to misunderstandings; individual beliefs can vary significantly even within the same affiliation.
B. Skipping the spiritual belief assessment is inappropriate as it is essential to understand the patient's unique beliefs and values to provide holistic care.
C. While a formal assessment tool can be helpful, it is not mandatory; what’s most important is engaging in a dialogue about the patient’s beliefs rather than strictly following a formal method.
D. It is crucial for the nurse to respect the patient's unique spiritual beliefs and not impose personal values, making this the most appropriate action to support the patient spiritually.

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The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

Correct Answer is A

Explanation

The nurse and the patient have the same religious affiliation. Which action will the nurse take to support the patient spiritually?

Correct Answer is D

Explanation

The patient is admitted with a diagnosis of chronic anxiety. Which action is most appropriate for the nurse to take when providing holistic care?

A registered nurse interprets that a scribbled medication prescription reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?

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A patient has been prescribed to receive 0.3 mL of U-500 insulin. Which syringe will the nurse use to administer the medication?

The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.)

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?

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