A 49-year-old male patient has been experiencing flu-like symptoms, including fever and chest congestion, for the past four days.
He visited the emergency department (ED) last night due to increased difficulty in breathing.
The patient has a 20-year history of smoking half a pack of cigarettes per day and has no significant medical or surgical history.
The nurse has placed the patient on a cardiorespiratory monitor and administered a nasal cannula. After completing an assessment, the nurse documented the findings in the patient’s chart.
Which assessment findings indicate hypoxia?
Productive cough
Respiratory rate of 28 breaths/minute
Oxygen saturation of 90% on room air
Heart rate of 101 beats/minute
Capillary refill of 4 seconds
Blood pressure of 145/89 mm Hg
Correct Answer : B,C,D
Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale
A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering the medication at 1000, 1600, 2200, and 0400 would not be the best schedule because it does not evenly distribute the doses throughout the day. This could lead to periods of subtherapeutic medication levels and periods of potential toxicity.
Choice B rationale
Administering the medication with meals and a bedtime snack is not the best schedule for this medication. While some medications need to be administered with food, there is no indication
that this medication needs to be. Furthermore, this schedule could lead to uneven distribution of the medication throughout the day.
Choice C rationale
Giving the medication in equally divided doses during waking hours is not the best schedule because it does not take into account the half-life of the medication or the patient’s sleep schedule. This could lead to subtherapeutic levels of the medication during the night.
Choice D rationale
Administering the medication at 0800, 1200, 1600, and 2000 is the best schedule for this medication. It evenly distributes the doses throughout the day, which can help maintain a therapeutic level of the medication and reduce the risk of toxicity.
Correct Answer is B
Explanation
Choice A rationale
While a high-calorie, high-protein diet can be beneficial for patients recovering from surgery or illness, it is not the immediate next step after collecting bone aspirate specimens for culture and sensitivity and applying a cast to a patient’s lower leg. The priority is to address the infection identified through the bone aspirate specimens.
Choice B rationale
Beginning parenteral antibiotic therapy is the appropriate next step after collecting bone aspirate specimens for culture and sensitivity in a patient with osteomyelitis. Osteomyelitis is an infection in the bone, and antibiotics are typically the first line of treatment. Therefore, this choice is the correct answer.
Choice C rationale
Administering antiemetic agents would be appropriate if the patient were experiencing nausea or vomiting. However, there is no indication in the question that the patient is experiencing these symptoms. Therefore, this choice is not the correct answer.
Choice D rationale
Bivalving the cast for distal compromise would be appropriate if there were signs of compromised circulation or nerve function below the level of the cast. However, there is no indication in the question that the patient is experiencing these issues. Therefore, this choice is not the correct answer.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
