A nurse is assessing a client who has hypoxemia for a late sign. Which finding should the nurse expect?
Hypertension
Tachycardia
Pallor
Bradypnea
The Correct Answer is C
A: Hypertension is not typically a late sign of hypoxemia. It can occur in various conditions but is not specific to hypoxemia.
B: Tachycardia is an early sign of hypoxemia as the body attempts to compensate for low oxygen levels by increasing the heart rate.
C: Pallor is a late sign of hypoxemia. It indicates poor oxygenation and perfusion, often seen when the body can no longer compensate for the lack of oxygen.
D: Bradypnea, or slow breathing, is not a typical sign of hypoxemia. Hypoxemia usually causes an increase in respiratory rate (tachypnea) as the body tries to take in more oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Wearing earphones is not part of the Rinne test. Earphones are used in other types of hearing tests, such as audiometry.
B: A small probe is not used in the Rinne test. Probes are used in other diagnostic procedures, such as tympanometry.
C: Small electrodes are not used in the Rinne test. Electrodes are used in tests like electroencephalography (EEG).
D: A tuning fork is placed on the mastoid bone behind the ear and then near the ear canal during the Rinne test. This test compares air conduction to bone conduction of sound.
Correct Answer is A
Explanation
A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.
B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.
C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.
D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.
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