The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

restlessness, confusion, tachycardia.

bradycardia, dyspnea, cyanosis.

hypotension, vomiting, cyanosis.

bradycardia, lethargy, confusion.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Restlessness, confusion, and tachycardia are early signs of hypoxia, indicating inadequate oxygenation.

Choice B rationale: Bradycardia, dyspnea, and cyanosis are more indicative of advanced hypoxia.

Choice C rationale: Hypotension, vomiting, and cyanosis may suggest severe hypoxia or other medical issues but are not typically early signs.

Choice D rationale: Bradycardia, lethargy, and confusion are not typical early signs of hypoxia.

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Correct Answer is D

Explanation

Choice A rationale: Suctioning is not typically performed as part of routine pulmonary nursing care every eight hours. It is indicated based on the client's clinical need.

Choice B rationale: Suctioning frequency should be determined by the client's condition and physician's orders, not a fixed hourly schedule.

Choice C rationale: Routine coughing and swallowing of sputum do not necessarily warrant suctioning. Suctioning is indicated when the client is unable to manage secretions effectively.

Choice D rationale: Suctioning is appropriate when the client has gurgling respirations and is unable to cough effectively, indicating the need to clear the airway.

A. read previous documentation on the client's chart. B. observe the client at rest and during activity. C. ask if shortness of breath is being experienced. D. auscultate lung sounds.

Correct Answer is B

Explanation

Choice A rationale: Reading previous documentation provides historical information but may not reflect the current level of dyspnea.

Choice B rationale: Observing the client at rest and during activity is the best way to assess the current level of dyspnea.

Choice C rationale: Asking if shortness of breath is being experienced provides subjective information but may not be as reliable as direct observation.

Choice D rationale: Auscultating lung sounds is important for assessing respiratory function but may not provide a comprehensive picture of dyspnea.

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The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes that the most appropriate reason to suction a client is that:

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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