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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Give the client a low sodium diet: SIADH causes retention of water and dilutional hyponatremia. Therefore, restricting sodium intake can help prevent further fluid retention and worsening of hyponatremia.
B. Monitor for serum electrolyte imbalances: SIADH can lead to electrolyte imbalances, particularly hyponatremia. Monitoring electrolyte levels, especially sodium, is essential for early detection and intervention.
C. Obtain daily weights: Monitoring daily weights is crucial for assessing fluid balance and detecting changes in hydration status, which is essential in clients with SIADH.
D. Educate the client on techniques to cope with thirst: Clients with SIADH often experience excessive thirst due to the body's inability to excrete excess water. Educating the client on strategies to manage thirst, such as chewing gum or sucking on ice chips, can help improve comfort.
E. Increase IV fluids: This option is incorrect because SIADH is characterized by water retention, so increasing IV fluids would exacerbate the condition and worsen hyponatremia.
Correct Answer is A
Explanation
A. Hypokalemia: Furosemide is a loop diuretic that works by increasing urinary excretion of sodium, chloride, and water, which can lead to potassium loss. Hypokalemia is a common electrolyte imbalance associated with the use of loop diuretics like furosemide. Potassium depletion can cause various complications, including cardiac dysrhythmias, muscle weakness, and fatigue.
B. Hypocalcemia: Furosemide does not directly affect calcium levels, so hypocalcemia is not a common electrolyte imbalance associated with its use.
C. Hypernatremia: Furosemide promotes the excretion of sodium, so hypernatremia (elevated serum sodium levels) is not typically a concern with its use.
D. Hyperkalemia: Furosemide can cause potassium loss, so hyperkalemia is not a risk associated with its use.
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