The nurse would expect to find which signs and symptoms of hypoxia?
Anxiety.
Erythema.
Restlessness.
Tachypnea.
Fever.
Correct Answer : A,C,D
Choice A rationale
Anxiety is often one of the earliest signs of hypoxia, as the brain perceives a decrease in oxygen saturation even before physical symptoms become severe. This subjective feeling of unease or dread is a physiological response to the sympathetic nervous system's activation as the body attempts to compensate for falling oxygen levels. In a clinical setting, unexplained or increasing anxiety should always prompt a thorough respiratory assessment and an evaluation of arterial oxygen levels.
Choice B rationale
Erythema refers to a redness of the skin, which is typically associated with inflammation, infection, or increased blood flow to a specific area. In contrast, hypoxia usually manifests as cyanosis, a bluish discoloration of the skin and mucous membranes, or pallor, due to a lack of oxygenated hemoglobin in the peripheral tissues. Therefore, erythema is not a clinical indicator of low oxygen levels and would instead suggest a different underlying physiological or dermatological issue.
Choice C rationale
Restlessness is a hallmark neurological sign of early hypoxia and is frequently observed in patients whose oxygen levels are starting to decline. As the cerebral cortex is highly sensitive to oxygen deprivation, the patient may become agitated, unable to sit still, or exhibit confused behavior. Normal peripheral oxygen saturation (SpO2) ranges between 95.
Choice D rationale
Tachypnea, or a rapid respiratory rate exceeding 20 breaths per minute, is a primary compensatory mechanism the body uses to increase oxygen intake and expel carbon dioxide. When oxygen levels drop, the chemoreceptors in the carotid and aortic bodies signal the respiratory center in the brain to increase the depth and frequency of breathing. Recognizing tachypnea is crucial for identifying respiratory distress early, as it signifies that the body is working harder to maintain homeostatic oxygenation.
Choice E rationale
Fever is an elevated body temperature, usually defined as 100.4°F (38°C) or higher, and is most commonly a response to infection, inflammation, or certain medications. While a fever increases the body's metabolic rate and consequently its demand for oxygen, it is not a direct sign or symptom of hypoxia itself. Hypoxia is the state of oxygen deficiency at the tissue level, whereas fever is a systemic thermoregulatory response to pyrogens or other internal stimuli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Obstructive sleep apnea (OSA) is characterized by the repetitive collapse of the upper airway during sleep, leading to periods of apnea and hypoxemia. A Continuous Positive Airway Pressure (CPAP) machine is the gold-standard treatment for OSA. It delivers a constant stream of pressurized air through a mask, which acts as a physical splint to keep the airway open. The nurse would expect this device to be present at the bedside for use whenever the client sleeps.
Choice A rationale
While supplemental oxygen may be used in some respiratory conditions, it is not the primary or standard treatment for obstructive sleep apnea. In OSA, the problem is a mechanical blockage of the airway, not necessarily a lack of ambient oxygen. Providing oxygen through a tank or concentrator without addressing the airway collapse does not prevent the apneic episodes. The CPAP is the specific tool designed to overcome the physiological obstruction that defines this specific sleep disorder.
Choice C rationale
An incentive spirometer is used to encourage deep breathing and prevent atelectasis, typically in postoperative patients or those with pneumonia. It helps expand the alveoli and clear secretions. However, it is a voluntary exercise performed while awake and does nothing to prevent the airway collapse that occurs during sleep in patients with OSA. While it is a common bedside respiratory tool, it is not a specific or indicated treatment for managing obstructive sleep apnea.
Choice D rationale
A pulse oximeter is a diagnostic tool used to monitor oxygen saturation, but it is not a treatment device. While a nurse might use a pulse oximeter to assess the severity of desaturation during sleep apnea events, the question asks for a device used to manage the condition. The pulse oximeter provides data but does not provide the therapeutic intervention needed to keep the airway patent. The CPAP machine is the therapeutic device expected for this diagnosis.
Correct Answer is D
Explanation
Choice A rationale
Metabolic acidosis is characterized by a primary decrease in bicarbonate or an accumulation of nonvolatile acids in the blood. While patients with severe illness can develop multiple imbalances, the primary issue in COPD is not metabolic in origin. In metabolic acidosis, the lungs typically respond by hyperventilating to blow off carbon dioxide to raise the pH. This is the opposite of the hypoventilation and carbon dioxide retention typically seen in patients with chronic obstructive pulmonary disease.
Choice B rationale
Respiratory alkalosis occurs when there is excessive elimination of carbon dioxide from the lungs, usually due to hyperventilation. This leads to an increase in blood pH levels above 7.45. In a client with severe COPD, the primary physiological challenge is the inability to exhale carbon dioxide effectively due to air trapping and alveolar destruction. Therefore, these patients are much more likely to retain carbon dioxide rather than eliminate too much of it through the respiratory system.
Choice C rationale
Metabolic alkalosis involves a primary increase in bicarbonate levels or a loss of metabolic acids, leading to a blood pH greater than 7.45. This condition can be caused by factors like prolonged vomiting or excessive diuretic use. While some COPD patients on certain medications might experience metabolic shifts, it is not the classic acid-base imbalance associated with the underlying pathophysiology of obstructive lung disease and the resulting chronic failure of the respiratory pump to clear gas.
Choice D rationale
Respiratory acidosis is the hallmark of severe COPD due to chronic airflow obstruction and impaired gas exchange. The damaged alveoli and narrowed airways lead to the retention of carbon dioxide, which is a physiological acid. As carbon dioxide levels rise above the normal range of 35 to 45 mmHg, the blood pH drops below 7.35. This client’s report of dyspnea with minimal exertion suggests a high level of CO2 retention and a state of chronic respiratory acidosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.