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A nurse is assessing a patient and notes that the patient is experiencing hypoxia.
Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

increased respiratory rate

confusion

cyanosis

restlessness

dyspnea

Bradychardia

Hypertension

Nausea and vomiting

Answer and Explanation

Correct Answer : A,B,C,D,E

The correct answer is choices A, B, C, D, and E.

Hypoxia occurs when there is inadequate oxygen supply to the body's tissues. Signs of hypoxia can vary depending on the severity of the condition. The following signs can indicate hypoxia:

Increased respiratory rate - Hypoxia can cause an increased respiratory rate as the body tries to increase oxygen levels in the blood.
Confusion - Hypoxia can affect cognitive function, leading to confusion.
Cyanosis - Hypoxia can cause a blue or purple discoloration of the skin, lips, or nail beds due to the lack of oxygen.
Restlessness - Hypoxia can cause restlessness or agitation.
Dyspnea - Hypoxia can cause difficulty breathing, also known as dyspnea.
Bradycardia - Bradycardia, or a slow heart rate, is not typically a direct sign of hypoxia. Hypoxia often leads to tachycardia (increased heart rate) as the body tries to compensate for low oxygen levels.
Hypotension - While severe hypoxia can eventually lead to changes in blood pressure, hypotension (low blood pressure) is not a primary sign of hypoxia. Typically, hypoxia might cause hypertension or have no immediate impact on blood pressure.
Nausea and Vomiting - While nausea and vomiting can be related to various conditions, they are not specific signs of hypoxia. These symptoms might occur due to other issues or as a secondary effect in some cases, but they are not primary indicators of hypoxia.

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Correct Answer is C

Explanation

Correct answer: C

C. The nurse turns and their back is facing the sterile field.Turning one’s back to the sterile field is a breach of sterile technique because it increases the risk of contamination. The sterile field must always be in the nurse’s line of sight to ensure it remains uncontaminated.

Incorrect Options:

A. The nurse applies sterile gloves and touches a sterile object in the sterile field.This is correct practice. Sterile gloves are used to handle sterile objects within the sterile field to maintain sterility.

B. The nurse disposes of an opened container of sterile saline after 24 hours.This is correct practice. Sterile saline should be discarded after 24 hours to prevent contamination.

D. The nurse keeps hands above waist level while donning sterile gloves.This is correct practice. Keeping hands above waist level helps maintain sterility by preventing contact with non-sterile surfaces.

A. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. B. Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction. C. Hold a finger 6-8 inches from the bridge of the patient's nose and move finger toward the patient's nose to observe pupil's reaction. D. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4-6 inches from the nose and observe for pupil constriction.

Correct Answer is B

Explanation

: Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction. This is the appropriate technique to assess pupillary reaction. The nurse should stand to the side of the patient and use a penlight or other focused light source to illuminate one pupil at a time. The light should be directed from the side of the eye, not directly in front of it, to avoid stimulating the accommodation reflex. The nurse should observe for constriction of the pupil, which should occur in response to the light. This assessment is important because changes in pupil size and reactivity can indicate neurological dysfunction or other medical conditions.

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A nurse is assessing a patient and notes that the patient is experiencing hypoxia. Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

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A nurse is assessing a patient and notes that the patient is experiencing hypoxia.
Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.