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

Drowsiness.

Jaundice.

Flushed pink cheeks.

Tachycardia.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Drowsiness is not a typical finding associated with hypoxia. Hypoxia often leads to increased alertness and anxiety as the body tries to compensate for the lack of oxygen. Drowsiness might be seen in severe cases of hypoxia, but it's not a consistent finding.

Choice B rationale:

Jaundice is not directly related to hypoxia. Jaundice is usually caused by elevated bilirubin levels due to liver dysfunction or other underlying issues. It is not a primary manifestation of hypoxia.

Choice C rationale:

Flushed pink cheeks can be an indicator of increased blood flow to the skin, which might occur as the body tries to compensate for hypoxia. However, this finding is not as consistent or specific as tachycardia in cases of hypoxia.

Choice D rationale:

Tachycardia, or an abnormally rapid heart rate, is a common physiological response to hypoxia. The body attempts to deliver more oxygen to tissues by increasing the heart rate. This compensatory mechanism helps maintain tissue perfusion in the face of reduced oxygen levels.

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Correct Answer is B

Explanation

Choice A rationale:

Auscultation at the pulmonic and mitral points would not provide the clearest hearing of the S2 heart sound. The S2 sound is composed of two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). The aortic valve sound (A2) is usually louder than P2. Mitral point is not ideal for hearing S2 clearly, as it's mostly associated with S1 sound.

Choice B rationale:

The tricuspid and aortic points are the most appropriate for hearing the S2 heart sound. The aortic valve (A2) is best heard at the second right intercostal space close to the sternum, and the tricuspid valve is best heard at the lower left sternal border.

Choice C rationale:

While the mitral and tricuspid points are important for auscultating the heart sounds, they are more associated with the S1 sound (the first heart sound). The S2 sound is best heard at the aortic and pulmonic areas.

Choice D rationale:

The aortic and pulmonic points are important for assessing the S2 heart sound, but they are not the most optimal locations. The aortic valve sound is heard most clearly at the second right intercostal space, whereas the pulmonic valve sound is heard at the second left intercostal space.

A. Use an internet webpage translator for the client. B. Arrange to complete the assessment with only the client and a translator present. C. Ask the client's husband to translate questions and answers for the client. D. Ask a male student nurse to translate for the client.

Correct Answer is B

Explanation

Choice A rationale:

Using an internet webpage translator might seem convenient, but it can lead to inaccuracies in communication due to language nuances and medical terminology. Direct communication with a human translator is more reliable.

Choice B rationale:

Arranging to complete the assessment with only the client and a translator present is the best option. This approach ensures accurate and confidential communication, allowing the nurse to gather essential information directly from the client without potential bias or misinterpretation from family members.

Choice C rationale:

Asking the client's husband to translate questions and answers for the client can lead to inaccurate or biased information. Additionally, it might not provide a safe environment for the client to openly share her concerns.

Choice D rationale:

Asking a male student nurse to translate for the client does not necessarily address the language barrier adequately. The gender of the translator is not the primary concern here. Ensuring effective communication through a professional translator is more important.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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