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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The pinnae of the ears may not provide an accurate assessment for cyanosis in clients with dark skin.

B. The dorsal surface of the hand can be misleading in clients with dark skin.

C. In clients with dark skin, cyanosis is best assessed in areas where the pigmentation is less prominent, such as the oral mucosal lining.

D. The dorsal surface of the foot is not an ideal site for assessing cyanosis in this client population.

A. Elevated glucose levels B. Dysrhythmias C. Elevated blood pressure D. Impaired airway

Correct Answer is A

Explanation

A. Hydrochlorothiazide is known to increase blood glucose levels, particularly in clients with diabetes or those at risk for glucose intolerance.

B. Dysrhythmias are more commonly associated with electrolyte imbalances like low potassium, but elevated glucose is more specific to hydrochlorothiazide use.

C. Hydrochlorothiazide typically lowers blood pressure, so elevated blood pressure is not a common nontherapeutic response.

D. Impaired airway is unrelated to hydrochlorothiazide use.

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You are examining a client with respiratory distress. Which physical assessment would best determine if the client has acute hypoxemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which part of the body should the nurse examine to identify cyanosis in this client?

Correct Answer is C

Explanation

A client is receiving the diuretic hydrochlorothiazide. When evaluating the client's response to hydrochlorothiazide, which common nontherapeutic response is important for the nurse to monitor?

Correct Answer is A

Explanation

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