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. A moderate-carbohydrate diet is recommended because carbohydrates increase CO₂ production during metabolism, and limiting excessive carbohydrate intake can help manage CO₂ retention in patients with respiratory issues.
B. Low-caffeine is not directly related to CO₂ retention and does not influence carbon dioxide levels in the body.
C. High-carbohydrate intake can exacerbate CO₂ production, worsening retention issues in patients with compromised lung function.
D. High-caffeine intake is not related to CO₂ retention management and would not impact CO₂ levels in the respiratory system.

A. Patient will increase activity level this shift. B. Patient will turn side to back to side with assistance every 2 hours. C. Patient will use the walker correctly to ambulate to the bathroom as needed. D. Patient will use a sliding board correctly to transfer to the bedside commode as needed.

Correct Answer is B

Explanation

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

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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

A patient is experiencing carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?

Correct Answer is A

Explanation

A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Correct Answer is B

Explanation

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