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 D
Explanation
Choice A rationale
Albuterol is a selective beta-2 adrenergic agonist and does not directly suppress the immune response. Corticosteroids are known for their immunosuppressive effects, but Albuterol's primary action is bronchodilation by acting on airway smooth muscle receptors, leading to relaxation and improved airflow without affecting immune cells.
Choice B rationale
While some beta-agonists can have a minor effect on glucose metabolism, leading to slight increases in blood sugar in some individuals, this is not a common or significant side effect associated with typical Albuterol use, especially compared to corticosteroids. Albuterol's primary mechanism involves adenyl cyclase activation, leading to bronchodilation.
Choice C rationale
Mouth sores are not a typical side effect of Albuterol. Oral candidiasis (thrush) can occur with inhaled corticosteroids due to localized immunosuppression and altered oral flora, but Albuterol, being a bronchodilator, does not have this effect. Mouth irritation is possible with any inhaled medication, but not true sores.
Choice D rationale
Albuterol is a beta-2 adrenergic agonist, and while it primarily targets beta-2 receptors in the lungs, it can have some systemic absorption and stimulate beta-1 receptors in the heart, especially with higher doses. This stimulation can lead to an increased heart rate (tachycardia) due to enhanced cardiac contractility and conduction.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Obtaining informed consent is a fundamental ethical and legal requirement before any invasive medical procedure, including a bronchoscopy. This ensures patient autonomy, allowing them to make an educated decision based on understanding the procedure's risks, benefits, and alternatives. The patient's signature indicates their voluntary agreement after a thorough discussion with the healthcare provider, demonstrating adherence to patient rights.
Choice B rationale
Flumazenil is a benzodiazepine receptor antagonist used to reverse the sedative effects of benzodiazepines. While benzodiazepines like midazolam are commonly used for conscious sedation during bronchoscopy, flumazenil is generally not kept readily available for routine use. It is an emergency reversal agent reserved for severe respiratory depression or over-sedation.
Choice C rationale
Ensuring the client is NPO (nil per os) for at least 6 hours prior to a bronchoscopy is crucial to prevent aspiration. The procedure involves manipulating the airway, which can stimulate the gag reflex and potentially lead to regurgitation of gastric contents into the lungs, causing aspiration pneumonia or acute respiratory distress. Fasting significantly reduces this risk.
Choice D rationale
Continuous monitoring of heart rate and oxygen saturation via a bedside heart monitor and pulse oximeter is essential during and after a bronchoscopy. This allows for immediate detection of adverse events such as hypoxemia, arrhythmias, or respiratory depression, enabling prompt intervention. Constant vigilance ensures patient safety throughout the procedure.
Choice E rationale
Midazolam, a short-acting benzodiazepine, is commonly used for conscious sedation during bronchoscopy. Its anxiolytic, sedative, and amnestic properties help to reduce patient anxiety, promote comfort, and minimize recall of the procedure. Its rapid onset and short duration of action make it suitable for outpatient procedures.
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