A nurse is assessing a client who has chronic emphysema. The client is receiving oxygen at 2 L/min via nasal cannula and is resting with the head of bed elevated to a 45° angle. Which of the following findings should the nurse identify as an early indication of hypoxia?
Decreased level of consciousness
Restlessness
Circumoral cyanosis
Seizures
The Correct Answer is B
A. Decreased level of consciousness: This is a late sign of hypoxia, indicating significant oxygen deprivation and possible brain involvement. Immediate intervention is required at this stage.
B. Restlessness: Restlessness is an early clinical manifestation of hypoxia. It reflects the body’s initial response to inadequate oxygenation, often presenting as anxiety, irritability, or agitation, and should prompt further assessment and intervention.
C. Circumoral cyanosis: Cyanosis around the mouth is a late sign of hypoxia, typically appearing after prolonged oxygen deprivation when oxygen saturation has significantly dropped.
D. Seizures: Seizures occur only in severe, prolonged hypoxia or hypoxemia affecting the central nervous system. This is a late and serious indicator of oxygen deprivation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,C,B,D
Explanation
A. Determine the client's airway patency: Ensuring the airway is patent is the highest priority in the immediate postoperative period because airway compromise can be life-threatening. This assessment is performed first to address the most critical physiological need.
B. Evaluate the client's level of consciousness: After airway and basic respiratory assessment, the nurse evaluates the client’s level of consciousness to detect neurological changes, sedation effects from anesthesia, or potential complications.
C. Auscultate the client's lung sounds: Respiratory assessment, including auscultation, identifies complications such as atelectasis or pneumonia. While vital, it follows confirming airway patency to prioritize immediate safety.
D. Ask the client to rate their pain: Pain assessment is important for comfort and recovery but is performed after addressing airway, breathing, and neurological status. It is lower priority compared with immediate physiological needs.
Correct Answer is B
Explanation
A. Metoprolol: Metoprolol is a beta-blocker used for hypertension or cardiac conditions. While it may affect blood pressure during the procedure, it is generally safe to continue and does not pose an immediate risk for colonoscopy.
B. Clopidogrel: Clopidogrel is an antiplatelet medication that increases the risk of bleeding. Because colonoscopy may involve biopsies or polypectomy, taking clopidogrel prior to the procedure significantly raises the risk of hemorrhage, making it the priority to report to the provider.
C. Metformin: Metformin is used to manage diabetes. It may require temporary discontinuation around procedures requiring contrast dye due to risk of lactic acidosis, but for a standard colonoscopy without contrast, it is less urgent than clopidogrel.
D. Digoxin: Digoxin is used for heart failure or arrhythmias. While monitoring for cardiac effects is important, digoxin does not pose an immediate risk for bleeding during colonoscopy and is not the priority to report.
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