Which clinical manifestation is most reflective of an early response to hypoxia?

Restlessness

Cyanosis

Apnea

Bradycardia

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Restlessness is often one of the earliest signs of hypoxia. When the body experiences low oxygen levels, the brain is one of the first organs to be affected. This can lead to symptoms such as anxiety, agitation, and restlessness as the brain struggles to function properly without adequate oxygen. These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing respiratory and heart rates, which can make a person feel uneasy or restless.

Choice B Reason:

Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. While cyanosis is a significant indicator of hypoxia, it is typically a later sign. By the time cyanosis is visible, hypoxia has usually been present for some time, and oxygen levels have been critically low. Therefore, it is not the earliest clinical manifestation of hypoxia.

Choice C Reason:

Apnea is the absence of breathing. This is a severe and late sign of hypoxia. When a person stops breathing, it indicates that the body has been deprived of oxygen for an extended period, leading to critical conditions. Apnea is a medical emergency and requires immediate intervention, but it is not an early sign of hypoxia.

Choice D Reason:

Bradycardia is a slower than normal heart rate. Like apnea, bradycardia is a late sign of hypoxia. Initially, the body responds to low oxygen levels by increasing the heart rate (tachycardia) to pump more oxygenated blood to tissues. Bradycardia occurs when the body can no longer compensate, and the heart rate slows down, indicating severe hypoxia and impending failure of the cardiovascular system.

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Correct Answer is D

Explanation

The correct answer is d) Tighten the abdominal muscles while exhaling.

Choice A Reason:

“Raise both shoulders while breathing deeply” is incorrect. Diaphragmatic breathing focuses on using the diaphragm rather than the shoulders. Raising the shoulders can lead to shallow chest breathing, which is less effective for oxygen exchange.

Choice B Reason:

“Inhale through the mouth” is incorrect. For diaphragmatic breathing, it is recommended to inhale through the nose. This helps filter, warm, and humidify the air before it reaches the lungs.

Choice C Reason:

“Exhale through the nose” is incorrect. While exhaling through the nose is beneficial in some breathing exercises, diaphragmatic breathing typically involves exhaling through pursed lips. This technique helps slow down the exhalation and keeps the airways open longer.

Choice D Reason:

“Tighten the abdominal muscles while exhaling” is correct. Tightening the abdominal muscles helps push the diaphragm up, forcing air out of the lungs more efficiently. This action is a key component of effective diaphragmatic breathing.

A. Urinary tract infection B. Deep vein thrombosis C. Constipation D. Atelectasis

Correct Answer is D

Explanation

Choice A Reason:

Urinary tract infections (UTIs) are typically caused by bacteria entering the urinary tract. While strict bed rest can increase the risk of UTIs due to factors like catheter use and reduced mobility, the use of an incentive spirometer does not directly prevent UTIs. Instead, preventing UTIs involves maintaining good hygiene, ensuring adequate fluid intake, and, if necessary, using catheters properly.

Choice B Reason:

Deep vein thrombosis (DVT) is a condition where blood clots form in the deep veins, usually in the legs. This can occur due to prolonged immobility, such as strict bed rest after surgery. Preventing DVT involves measures like using compression stockings, administering anticoagulant medications, and encouraging leg exercises. An incentive spirometer, which is used to improve lung function, does not directly prevent DVT.

Choice C Reason:

Constipation is a common issue for patients on bed rest due to reduced physical activity and changes in diet. Preventing constipation involves ensuring adequate hydration, providing a high-fiber diet, and encouraging as much physical activity as possible. The use of an incentive spirometer, which focuses on respiratory function, does not directly address constipation.

Choice D Reason:

Atelectasis is a condition where the alveoli in the lungs collapse, leading to reduced or absent breath sounds in the affected areas. This is a common postoperative complication, especially in patients on strict bed rest, due to shallow breathing and reduced lung expansion. The use of an incentive spirometer encourages deep breathing and helps to keep the alveoli open, thereby preventing atelectasis. This is why the incentive spirometer is an essential tool for postoperative respiratory care.

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Which clinical manifestation is most reflective of an early response to hypoxia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is demonstrating to a client how to perform diaphragmatic breathing. The nurse should educate the client to complete which action?

Correct Answer is D

Explanation

A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

Correct Answer is D

Explanation

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?

A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

A nurse is caring for a client admitted with a rash. They are trying to rule out (r/o) varicella. Before entering the room, the nurse should be instructed to wear what kind of mask?

A nurse is caring for a client who has returned to the unit following a surgical procedure of the abdomen. The client is complaining of pain 6/10. On assessment, the client’s oxygen saturation is 85%. Which action should the nurse take first?

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which action should the nurse take?

A client has an order for continuous bladder irrigation. What should the nurse do with the irrigation solution on the intake and output (I&O) sheet when calculating the fluid balance for this client?

A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?

The nurse is providing education to a client about nutrition. Which foods should the client be instructed to limit in their diet? (Select all that apply)