A nurse suspects impending respiratory failure in a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse should recognize that which assessment finding supports the presence of hypoxemia?
The client has circumoral cyanosis.
The client's heart rate is 86 bpm.
The client has a pulse ox of 90% on room air.
The client is lethargic.
The Correct Answer is C
A. The client has circumoral cyanosis: Circumoral cyanosis, or bluish discoloration around the mouth, is a sign of hypoxia but may not be present in all cases of hypoxemia. Pulse oximetry provides a more objective measurement.
B. The client's heart rate is 86 bpm: Heart rate may be within normal limits even in the presence of hypoxemia, as compensatory mechanisms may not be fully activated.
C. The client has a pulse ox of 90% on room air: A pulse oximetry reading of 90% indicates hypoxemia (oxygen saturation below normal levels), which is a significant finding, especially in a client with COPD who may already have compromised respiratory function.
D. The client is lethargic: Lethargy may occur with severe hypoxemia, but it is a late sign and may not always be present. Monitoring oxygen saturation is more reliable for early detection of hypoxemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is "{\"xRanges\":[104.2578125,134.2578125],\"yRanges\":[114.30078125,144.30078125]}"
Explanation
Correct Answer is D
Explanation
A. The client expresses feelings of frustration and difficulty coping with the chronic nature of RA: This indicates the client is struggling emotionally, which is common in chronic illnesses but does not directly reflect the effectiveness of the RA treatment regimen.
B. The client's C-reactive protein (CRP) levels have remained stable since the initiation of treatment: While stable CRP levels can indicate control of inflammation, they do not show improvement. Ideally, effective treatment would reduce CRP levels.
C. The client demonstrates improved range of motion in the affected joints during physical therapy sessions: Improved range of motion is a positive outcome, but it may not fully represent the overall effectiveness of the RA treatment, as joint damage can still progress.
D. The client's radiographic images show no progression of joint erosion compared to images from six months ago: This is the best indicator of effective RA management as it directly shows that the treatment is preventing further joint damage, which is a primary goal in managing RA.
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