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 C
Explanation
Choice A rationale
While avoiding exposure to large crowds can help prevent infections, especially for patients with compromised immune systems, it is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Choice B rationale
While emotional support is important for patients dealing with health issues, calling a crisis hotline if feeling lonely is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Choice C rationale
This is the most crucial information for the patient. Acetaminophen is found in many over-the- counter medications, and further intake could exacerbate liver damage.
Choice D rationale
While a balanced diet is important for overall health, following a high carbohydrate, low fat, low protein diet is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Correct Answer is ["1.8"]
Explanation
The client weighs 132 pounds. To convert pounds to kilograms, divide the weight in pounds by
2.2. So, the client’s weight in kilograms is: Step 1: 132 pounds ÷ 2.2 = 60 kg The prescription for dantrolene is 1.5 mg/kg. To find out how many milligrams the client should receive, multiply the client’s weight in kilograms by the dosage in mg/kg: Step 2: 60 kg × 1.5 mg/kg = 90 mg The vial is reconstituted to yield a concentration of 50 mg/mL. To find out how many mL the nurse should administer, divide the total dosage in milligrams by the concentration in mg/mL: Step 3: 90 mg ÷ 50 mg/mL = 1.8 mL So, the nurse should administer 1.8 mL of dantrolene.
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