Which of the following clinical findings suggests the patient with COPD is experiencing hypoxia?
Cyanotic nail beds
Decreased blood pressure
Bradycardia
Elevated temperature
The Correct Answer is A
A. Cyanotic nail beds: Chronic obstructive pulmonary disease leads to impaired gas exchange and chronic hypoxemia. Cyanosis, a bluish discoloration of the distal extremities and mucous membranes, occurs when the concentration of deoxygenated hemoglobin in the capillaries exceeds 5 g/dL. It is a direct clinical indicator of inadequate tissue oxygenation.
B. Decreased blood pressure: Hypotension is not a specific or early sign of hypoxia in a patient with COPD. While severe, acute hypoxia can eventually lead to circulatory collapse, the body's initial compensatory response to low oxygen is typically sympathetic activation. This would more likely cause a transient increase in blood pressure rather than a decrease.
C. Bradycardia: A decreased heart rate is a late and ominous sign of severe, prolonged hypoxia, often indicating imminent cardiac arrest. In the early stages of hypoxia, the body compensates with tachycardia to increase cardiac output and oxygen delivery to the tissues. A healthy heart responds to falling oxygen levels by beating faster.
D. Elevated temperature: Fever is a systemic response to infection or inflammation and is not a direct physiological result of low blood oxygen levels. While an infection may be the cause of a COPD exacerbation leading to hypoxia, the elevated temperature itself does not signify a lack of oxygen. Hypoxia is a respiratory and circulatory finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Conducting a new comprehensive medical history:A comprehensive history is part of the initial assessment phase of the nursing process, not the evaluation phase. While new information may emerge, the purpose of evaluation is to measure the response to specific interventions already implemented. It focuses on current outcomes rather than past medical events.
B. Reassessing patient pain level and functionality:Evaluation requires comparing the patient's current status against the established baseline and goals. The nurse must determine if the pain score has decreased and if the patient can now perform essential tasks like deep breathing. This step validates whether the chosen intervention was clinically effective.
C. Administering additional interventions from another category:Implementing new interventions is a part of the planning or implementation phases, not evaluation. Evaluation must occur first to determine if current treatments are failing before new ones are added. Prematurely changing the plan without evaluation leads to fragmented and uncoordinated patient care.
D. Assuring the patient always takes medications consistently:Monitoring medication adherence is an ongoing implementation task rather than an evaluation of the drug's efficacy. Evaluation focuses on the physiological and subjective impact of the drug on the patient's pain. Adherence does not guarantee that the prescribed dose is actually meeting the patient's needs.
Correct Answer is A
Explanation
A. Asthma:While asthma causes wheezing due to bronchoconstriction, it does not typically cause a global decrease in breath sounds unless the attack is severe and air movement is minimal. In many cases of asthma, breath sounds are audible but adventitious. Decreased sounds suggest a more significant barrier to air transmission.
B. Normal lung function:Normal lung function is characterized by clear, vesicular breath sounds in the periphery and bronchial sounds over the larger airways. Decreased or absent breath sounds are always an abnormal finding that requires further investigation. They indicate an interruption in the normal transmission of sound through the lung tissue.
C. Bronchitis:Bronchitis typically manifests as loud, coarse rhonchi or wheezes caused by mucus and inflammation in the large airways. Breath sounds are usually present but distorted by the adventitious noises. It does not typically result in the diminished intensity of sound associated with "decreased" breath sounds.
D. Pleural effusion:The accumulation of fluid in the pleural space acts as a physical barrier that dampens the transmission of sound from the lungs to the chest wall. This results in significantly diminished or absent breath sounds over the area of the effusion. It is a classic clinical finding for this pathological state.
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