The nurse recognizes that the primary physiologic problem affecting clients with emphysema is:

Maintaining adequate oxygenation is the primary goal for a client with impaired gas exchange due to an asthma exacerbation. Pulse oximetry is a non-invasive method to monitor the oxygen saturation of a patient’s blood, and values above 94% indicate sufficient oxygenation.

Choice A reason:

The client will demonstrate decreased episodes of coughing at night is important but not the priority goal. While reducing coughing can improve comfort and sleep quality, it does not directly address the critical issue of impaired gas exchange. The primary concern in an asthma exacerbation is ensuring that the client maintains adequate oxygen levels.

Choice B reason:

The client’s pulse oximetry values will remain above 94% on room air for the majority of the time is the priority goal. This goal directly addresses the issue of impaired gas exchange by ensuring that the client maintains adequate oxygenation. Pulse oximetry values above 94% indicate that the client’s blood is sufficiently oxygenated, which is crucial for preventing hypoxemia and ensuring that the body’s tissues receive enough oxygen to function properly.

Choice C reason:

The client’s breath sounds will only have slight wheezing by discharge is a relevant goal but not the priority. While reducing wheezing is an indicator of improved airway function, it is not as directly measurable or critical as maintaining adequate oxygen saturation. Wheezing can persist even when oxygen levels are adequate, so it is not the most reliable indicator of improved gas exchange.

Choice D reason:

The client will correctly demonstrate the use of a peak flow meter is an important educational goal but not the priority in an acute setting. Proper use of a peak flow meter can help the client monitor their asthma and prevent future exacerbations, but it does not directly address the immediate issue of impaired gas exchange. The priority in an acute asthma exacerbation is to ensure that the client is adequately oxygenated.

Early signs of hypoxia, which is a condition where the body or a region of the body is deprived of adequate oxygen supply, often include symptoms such as restlessness, confusion, and tachycardia (rapid heart rate). These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing heart rate and causing a state of agitation or confusion.

Choice A reason:

Bradycardia, lethargy, confusion are not typically early signs of hypoxia. Bradycardia (slow heart rate) is more commonly associated with severe or prolonged hypoxia rather than early stages. Lethargy and confusion can occur, but they are not as immediate as restlessness and tachycardia.

Choice B reason:

Hypotension, vomiting, cyanosis are also not early signs of hypoxia. Hypotension (low blood pressure) and cyanosis (bluish discoloration of the skin) are more advanced signs indicating severe hypoxia. Vomiting is not a common symptom of hypoxia and is more likely related to other conditions.

Choice C reason:

Bradycardia, dyspnea, cyanosis includes symptoms that are more indicative of advanced hypoxia. Dyspnea (difficulty breathing) and cyanosis are signs that the body has been deprived of oxygen for a longer period. Bradycardia is not an early sign and usually occurs later in the progression of hypoxia.

Choice D reason:

Restlessness, confusion, tachycardia are classic early signs of hypoxia. Restlessness and confusion occur due to the brain’s response to low oxygen levels, while tachycardia is the body’s attempt to increase oxygen delivery to tissues by pumping blood more rapidly. These symptoms are the body’s initial compensatory mechanisms to address the lack of oxygen.