Exhibits here

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia.

Answer and Explanation

The Correct Answer is []

Cardiovascular

- Capillary refill 4 seconds

- A prolonged capillary refill time indicates poor peripheral perfusion, which can be a sign of hypoxia. Hypoxia can lead to reduced oxygen delivery to the tissues, resulting in delayed capillary refill.

Respiratory

- Oxygen saturation 90% on room air

- An oxygen saturation level of 90% is below the normal range (95-100%) and indicates that the blood is not adequately oxygenated, which is a direct sign of hypoxia.

- Respiratory rate 28 breaths/minute

- An elevated respiratory rate (tachypnea) is a common compensatory mechanism in response to hypoxia. The body attempts to increase oxygen intake and carbon dioxide expulsion by breathing more rapidly.

Neurological

- Anxious

- Anxiety can be a symptom of hypoxia. When the brain and other vital organs do not receive enough oxygen, it can trigger a sense of anxiety and restlessness as part of the body's alarm system.

- Restless

- Restlessness is another common symptom of hypoxia. It occurs because the body is trying to compensate for the lack of oxygen, leading to increased agitation and an inability to remain
calm.

Rationales for the Incorrect Choices:

- Cardiovascular

- Heart rate 101 beats/minute: While an elevated heart rate can be a compensatory response to hypoxia, it alone does not directly indicate hypoxia.
- Blood pressure 145/89 mm Hg: Elevated blood pressure is not a direct indicator of hypoxia and can be influenced by various factors including anxiety and pain.

- Respiratory

- Productive cough: A productive cough suggests respiratory infection or inflammation but does not directly measure oxygenation status or indicate hypoxia.

- Neurological

- Awake and alert: Being awake and alert indicates normal mental status and does not suggest hypoxia. Hypoxia typically affects cognitive function, leading to confusion or decreased level of consciousness in more severe cases.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Bruising of the skin is not typically associated with acute gastritis caused by contaminated water. While bruising may be a sign of other medical conditions or complications, it is not directly related to gastritis.

B. Low-grade fever can be a symptom of gastritis, especially if it is caused by an infectious agent. However, it is not typically a severe or emergent symptom that requires immediate reporting unless it is accompanied by other concerning symptoms.

C. Abdominal cramping is a common symptom of gastritis and may occur due to inflammation of the stomach lining. While it should be monitored, it is not as concerning as the potential complication indicated by option D.

D. Bloody emesis (vomiting blood) is a serious symptom that can indicate severe gastritis or complications such as gastrointestinal bleeding. It is essential to report this symptom promptly as it may require immediate medical attention and intervention.

A. A Repeated requests for attention from the nurse. B. B Periodic sighing and shaking the head. C. C Argumentativeness and use of profanity. D. D Decreased activity level and change in affect.

Correct Answer is C

Explanation

A. While repeated requests for attention from the nurse might indicate distress, they are not necessarily indicative of potential aggression or disruptive behavior.
B. Periodic sighing and shaking the head could suggest the client's emotional state, but they are not as indicative of potential aggression or disruptive behavior as argumentativeness and profanity.
C. Monitoring for argumentativeness and the use of profanity is crucial as they can escalate into disruptive or potentially aggressive behavior. It's important to assess the client's agitation level and ensure the safety of both the client and others on the mental health unit.

D. Decreased activity level and a change in affect may suggest a worsening of the client's mental state but are not immediate concerns in terms of safety on the unit.

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Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.

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Naxlex Comprehensive Predictor Exams

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is D

Explanation

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is C

Explanation

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

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Exhibits Which 2 orders should the nurse complete first?

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While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Exhibits here

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia.