A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?

Bradypnea

Restlessness

Hypertension

Tachycardia

Answer and Explanation

The Correct Answer is D

A. Bradypnea: Bradypnea (slow breathing) is not a typical late sign of hypoxia. Instead, clients with worsening hypoxia often develop tachypnea (rapid breathing) as the body tries to compensate for low oxygen levels.

B. Restlessness: Restlessness is an early sign of hypoxia, not a late one. It occurs due to inadequate oxygenation of the brain, leading to agitation and confusion.

C. Hypertension: Hypertension can be an early response to hypoxia as the body attempts to increase oxygen delivery. However, as hypoxia progresses, blood pressure may drop due to worsening oxygen deprivation.

D. Tachycardia: Tachycardia (increased heart rate) is a late sign of hypoxia. The heart compensates for low oxygen levels by increasing cardiac output. However, if untreated, hypoxia can progress to bradycardia and cardiac arrest.

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Correct Answer is A

Explanation

A. "I should apply clean dressings over the top of blood-saturated dressings and hold pressure.” This prevents disruption of clot formation and controls bleeding.

B. "I can clean wounds with hydrogen peroxide.” Hydrogen peroxide can damage healthy tissue and delay healing.

C. "I can carefully remove the object from a penetrating wound.” Objects should be left in place until medical professionals remove them.

D. "I should place the affected area in a dependent position.” Elevating an injured limb helps reduce swelling and bleeding.

A. “I'm sure your situation will get better with time." B. "It must be terrible to be in this situation." C. "If I were you, I would talk with the hospital chaplain." D. “Tell me what you have done in the past to cope with your problems.”

Correct Answer is D

Explanation

A. “I'm sure your situation will get better with time." This response is dismissive and does not acknowledge the client’s feelings. It provides false reassurance rather than support.

B. "It must be terrible to be in this situation." While this statement attempts empathy, it may sound judgmental or patronizing rather than encouraging meaningful discussion.

C. "If I were you, I would talk with the hospital chaplain." This response assumes what the client should do rather than exploring their current coping mechanisms. It does not encourage self-reflection.

D. “Tell me what you have done in the past to cope with your problems.” This response uses therapeutic communication by allowing the client to reflect on past coping strategies and explore potential solutions.

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A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?

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