You are examining a client with respiratory distress. Which physical assessment would best determine if the client has acute hypoxemia?
Inspect the nailbeds for the presence of clubbing.
Inspect the nailbeds and mucous membranes for the presence of cyanosis.
Palpate for areas of decreased tactile fremitus.
Auscultate for the presence of any adventitious breath sounds.
The Correct Answer is B
A. Clubbing is a sign of chronic hypoxia, not acute hypoxemia.
B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an indicator of acute hypoxemia.
C. Palpating for decreased tactile fremitus is related to fluid or air in the lungs, not specifically hypoxemia.
D. Auscultation for adventitious breath sounds can reveal respiratory issues but does not directly confirm hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Pale yellow urine would not be expected, as dehydration often leads to concentrated, dark urine.
B. Flat neck veins are a sign of dehydration and decreased fluid volume.
C. Hypotension is expected with dehydration due to a drop in circulating blood volume.
D. Poor skin turgor is a common indicator of dehydration as the skin loses elasticity.
E. Bradycardia is not expected; rather, tachycardia is more common in dehydration as the body tries to compensate for fluid loss.
Correct Answer is B
Explanation
A. The lateral position is typically not used for breast examination.
B. The sitting position is the standard initial position for a breast examination to observe breast symmetry and any abnormalities.
C. The Trendelenburg position is inappropriate for breast examination.
D. Standing is not typically used for breast examination; the client may be asked to stand later for certain aspects, but the sitting position is preferred initially.
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