A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?

Cyanosis

Hypotension

Bradycardia

Tachycardia

Answer and Explanation

The Correct Answer is D

A) Cyanosis:
Cyanosis, which is a bluish discoloration of the skin and mucous membranes, typically occurs with severe hypoxia or oxygen deprivation, usually when oxygen saturation levels drop below 85%. Cyanosis is a late sign of hypoxia, not an early sign. In the early stages of hypoxia, the body attempts to compensate, and cyanosis does not typically appear until oxygen levels are significantly low.

B) Hypotension:
While hypotension can be a consequence of severe or prolonged hypoxia, it is generally a late sign. In the early stages of hypoxia, the body compensates through mechanisms such as tachycardia and vasoconstriction, so hypotension would not be expected at this stage. Hypotension in a hypoxic patient usually signals progression to severe respiratory or circulatory failure.

C) Bradycardia:
Bradycardia (slow heart rate) is not typically associated with early hypoxia. Instead, the body tries to compensate for reduced oxygen levels by increasing heart rate (tachycardia) in the early stages. Bradycardia can occur in more severe stages of hypoxia, particularly if the body begins to struggle with compensating or if the patient progresses to a more critical state. However, it is not an early sign of hypoxia.

D) Tachycardia:
Tachycardia (an elevated heart rate) is an early compensatory mechanism that the body employs when oxygen levels are insufficient. The heart increases its rate to pump more blood (and thus oxygen) to vital organs and tissues. Tachycardia is one of the earliest signs of hypoxia and occurs as the body attempts to compensate for the decreased oxygen levels in the bloodstream.

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Correct Answer is A

Explanation

A) Respiratory acidosis:
This condition is characterized by an increase in PaCO2 and a decrease in pH, which is exactly what is seen in these ABG results. The pH of 7.21 indicates acidosis (normal pH range is 7.35–7.45), and the PaCO2 of 50 is elevated (normal PaCO2 range is 35–45 mmHg), indicating that carbon dioxide retention is contributing to the acidosis. In respiratory acidosis, the lungs are unable to adequately expel CO2, leading to an accumulation of CO2 in the blood, which decreases the pH. The HCO3 (bicarbonate) is within normal range (22–28 mEq/L), suggesting that there has not yet been compensation by the kidneys, which would typically increase bicarbonate levels to buffer the acidosis.

B) Metabolic alkalosis:
Metabolic alkalosis is characterized by an elevated pH (above 7.45) and an elevated HCO3 (above 28 mEq/L). In this case, the pH is low (7.21), and the bicarbonate level (HCO3) is normal (26), so metabolic alkalosis is not the correct diagnosis.

C) Respiratory alkalosis:
Respiratory alkalosis occurs when there is decreased PaCO2 (below 35 mmHg) and an elevated pH (above 7.45), typically due to hyperventilation. Since the PaCO2 is elevated (50 mmHg) in this case, it rules out respiratory alkalosis.

D) Metabolic acidosis:
Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO3 (below 22 mEq/L). While the pH is low in this case, the HCO3 is normal (26 mEq/L), which suggests that the acidosis is not metabolic in origin. Metabolic acidosis would typically show a low bicarbonate level, indicating that the kidneys are not able to compensate effectively.

A. It is pain that can be relieved with rest B. It is normal pain that will go away on its own on C. It is pain that is not relieved by taking nitroglycerin D. It is pain that requires a cardiac catheterization

Correct Answer is A

Explanation

A) It is pain that can be relieved with rest:
Stable angina is typically predictable and occurs during physical exertion or emotional stress when the heart’s oxygen demand exceeds its supply. The pain associated with stable angina usually resolves with rest or after the cessation of the activity that triggered it. Additionally, nitroglycerin can help alleviate the discomfort by dilating blood vessels and improving blood flow to the heart muscle.

B) It is normal pain that will go away on its own:
Although stable angina pain may resolve on its own when the precipitating factor (e.g., exercise or stress) is removed, it is not considered "normal" pain. The pain is a symptom of underlying coronary artery disease (CAD), indicating that the heart muscle is not getting enough oxygen. It’s important for the client to manage angina carefully, as it may progress to more serious forms, such as unstable angina or myocardial infarction (heart attack), if not addressed appropriately.

C) It is pain that is not relieved by taking nitroglycerin:
Nitroglycerin is commonly effective in relieving stable angina by relaxing the coronary arteries and improving blood flow to the heart. If a client’s angina is not relieved by nitroglycerin, it may indicate that the angina is no longer stable (i.e., it has become unstable angina) or that a more serious cardiovascular event is occurring, such as a heart attack.

D) It is pain that requires a cardiac catheterization:
Cardiac catheterization is a diagnostic and interventional procedure typically used when a patient has unstable angina or a history of myocardial infarction or when other treatments have failed. However, stable angina usually does not require immediate catheterization unless the pain is refractory or there is evidence of significant coronary artery blockage. The most common management for stable angina is lifestyle modifications, medications (e.g., nitroglycerin, beta-blockers, calcium channel blockers), and addressing risk factors for coronary artery disease.

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A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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