A nurse is assessing a client who has hypoxemia for a late sign. Which finding should the nurse expect?

Hypertension

Tachycardia

Pallor

Bradypnea

Answer and Explanation

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.

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Correct Answer is B

Explanation

A: Applying petroleum jelly to the client’s lips after oral care can help prevent dryness and cracking, but it is not the primary action to ensure safety during oral care.

B: Turning the client on his side before starting oral care is the correct action. This position helps prevent aspiration of fluids and secretions during the procedure, ensuring the client’s safety.

C: Using the thumb and index finger to keep the client’s mouth open is not safe or effective. A mouth prop or padded tongue blade should be used instead.

D: Using a stiff toothbrush can cause damage to the gums and oral tissues. A soft-bristled toothbrush is recommended for gentle and effective cleaning.

A. Clostridium difficile B. Antibiotic therapy C. Formula intolerance D. Bacterial contamination

Correct Answer is C

Explanation

A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.

B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.

C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.

D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.

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A nurse is assessing a client who has hypoxemia for a late sign. Which finding should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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