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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Correct Answer is A

Explanation

A. Ensure that the infant's crib mattress is firm. A firm mattress reduces the risk of SIDS by preventing the infant from sinking into a soft surface, which can obstruct breathing.

B. Prop the infant with a pillow when in a side-lying position. Propping with a pillow is not recommended as it can increase the risk of suffocation and is not a recommended SIDS prevention measure.
C. Place the infant in a prone position whenever possible. Placing an infant in a prone (stomach) position is a significant risk factor for SIDS. Infants should be placed on their backs to sleep.
D. Swaddle the infant in a blanket for sleeping. While swaddling can be safe if done correctly, it is not as critical as ensuring a firm mattress. Additionally, improper swaddling can pose risks if the blanket becomes loose.

A. Leave the room and close the door quietly. B. Ignore the behavior and hang the IV antibiotic. C. Complete an unusual occurrence report. D. Tell the client to stop the inappropriate behavior.

Correct Answer is A

Explanation

A. Leave the room and close the door quietly. Respecting the client's privacy is essential. The nurse should leave the room quietly and return later to administer the medication.
B. Ignore the behavior and hang the IV antibiotic. Ignoring the behavior and proceeding with the medication administration would violate the client's privacy.
C. Complete an unusual occurrence report. This situation does not require an incident report; it is a private matter between the client and the visitor.
D. Tell the client to stop the inappropriate behavior. The behavior is not necessarily inappropriate within the context of the client's rights to privacy and intimacy.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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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.