Which of the following is an EARLY sign of patient hypoxia?
Cyanosis.
Bradycardia.
Hypotension.
Agitation.
The Correct Answer is D
Choice A rationale
Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late and ominous sign of hypoxia. It becomes clinically apparent when there are approximately 5 grams per deciliter of desaturated hemoglobin. This indicates a significant reduction in oxygen saturation and severe tissue hypoxia, representing a decompensated physiological state.
Choice B rationale
Bradycardia, a slower than normal heart rate (normal range 60-100 beats per minute for adults), is typically a late sign of hypoxia, particularly in adults. Initially, the body often compensates for hypoxia with tachycardia to increase cardiac output and oxygen delivery. Profound and prolonged hypoxia can depress myocardial function, leading to bradycardia.
Choice C rationale
Hypotension, a low blood pressure (normal range systolic 90-120 mmHg, diastolic 60-80 mmHg), is generally considered a late sign of hypoxia. In the early stages, the sympathetic nervous system may initially increase blood pressure as a compensatory mechanism. However, prolonged or severe hypoxia can lead to myocardial depression and vasodilation, resulting in hypotension.
Choice D rationale
Agitation is an early neurological sign of hypoxia. As oxygen levels decrease, cerebral hypoxia affects brain function, leading to irritability, restlessness, and confusion. The brain is highly sensitive to oxygen deprivation, and these behavioral changes are often among the first indicators of inadequate oxygenation, preceding more overt physiological decompensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Placing an NG tube could potentially worsen a basilar skull fracture or cause further injury by penetrating the cranial vault if the cribriform plate is compromised. This intervention is contraindicated when clear fluid, possibly cerebrospinal fluid, is draining from the nose, indicating a potential breach in the dura mater.
Choice B rationale
Testing the clear fluid for the presence of glucose is a critical diagnostic step. Cerebrospinal fluid (CSF) contains glucose, whereas nasal secretions do not. A positive glucose test strongly indicates a CSF leak, which is a significant complication of facial trauma that requires specific management to prevent intracranial infection. Normal CSF glucose ranges from 40 to 70 mg/dL.
Choice C rationale
Encouraging coughing and deep breathing would increase intrathoracic and intracranial pressure, which could exacerbate a CSF leak and potentially introduce pathogens into the intracranial space. This action should be avoided as it poses a risk for further neurological complications such as meningitis.
Choice D rationale
Placing a mustache dressing on the patient might absorb the drainage but does not address the underlying issue of a potential CSF leak. Furthermore, applying pressure or occluding the nares could impede the free flow of CSF, potentially leading to a build-up of pressure and increasing the risk of retrograde infection into the central nervous system.
Correct Answer is B
Explanation
Choice A rationale
Vecuronium is a neuromuscular blocking agent, not an anxiolytic. Its primary mechanism of action involves competitive antagonism of acetylcholine at the nicotinic receptors on the motor endplate, leading to muscle paralysis. It does not possess anxiolytic properties, and administering it without concurrent sedation would cause significant distress to a conscious patient who is paralyzed but fully aware.
Choice B rationale
Vecuronium facilitates ventilation by inducing skeletal muscle paralysis, thereby preventing spontaneous breathing and patient-ventilator asynchrony. This allows for precise control of ventilation parameters in critically ill patients, reducing oxygen consumption by respiratory muscles and improving gas exchange. This paralysis is crucial in conditions like ARDS where high airway pressures and controlled ventilation are often required.
Choice C rationale
Vecuronium does not directly decrease inflammation. Its action is specific to the neuromuscular junction, leading to muscle relaxation and paralysis. While mechanical ventilation facilitated by vecuronium can indirectly reduce lung injury by optimizing ventilation, it does not have intrinsic anti-inflammatory properties at a molecular or cellular level. Anti-inflammatory medications would be administered separately if indicated.
Choice D rationale
Vecuronium is not an antimicrobial agent and has no direct activity against infectious pathogens. Its therapeutic role is limited to inducing muscle paralysis for medical procedures or to facilitate mechanical ventilation. Treating infection requires specific antibiotics or antiviral medications. Administering vecuronium would not address the underlying infectious process in a patient with ARDS.
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