Which clinical manifestation is most reflective of an early response to hypoxia?
Restlessness
Cyanosis
Apnea
Bradycardia
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Encouraging coughing and deep breathing is important for postoperative care to prevent complications such as atelectasis and pneumonia. However, with an oxygen saturation of 85%, the immediate priority is to address the client’s hypoxemia. Once oxygen levels are stabilized, coughing and deep breathing exercises can be encouraged.
Choice B reason: Elevating the client to a high Fowler’s position can help improve lung expansion and ease breathing. While this is a beneficial intervention, it is not the first priority when the client’s oxygen saturation is critically low. Administering oxygen should be the initial step to quickly improve oxygenation.
Choice C reason: Administering prescribed analgesic medication is essential for managing the client’s pain, which can also help improve breathing patterns. However, pain management should follow the immediate correction of hypoxemia. Ensuring adequate oxygenation takes precedence over pain relief in this scenario.
Choice D reason: Administering oxygen at 2 L/min is the first action the nurse should take. With an oxygen saturation of 85%, the client is experiencing significant hypoxemia, which needs to be corrected promptly to prevent further complications. Oxygen therapy will help increase the oxygen levels in the blood and improve the client’s overall condition.
Correct Answer is B
Explanation
Choice A reason: Placing a surgical mask on the client during transport is not the primary precaution for C. difficile infections. C. difficile is primarily transmitted through contact with contaminated surfaces and not through respiratory droplets. Therefore, while masks may be used for other infections, they are not the main precaution for C. difficile.
Choice B reason: Using gown and gloves when entering the room is essential for preventing the spread of C. difficile. This infection is highly contagious and can be transmitted through contact with contaminated surfaces or feces. Gown and gloves provide a barrier that helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice C reason: Using an alcohol-based agent to perform hand hygiene is not effective against C. difficile spores. Hand washing with soap and water is recommended because it is more effective at removing the spores from the hands. Alcohol-based hand sanitizers do not kill C. difficile spores and should not be relied upon for hand hygiene in this context.
Choice D reason: Obtaining a blood specimen to test for C. difficile is not the standard diagnostic method. C. difficile infections are typically diagnosed through stool tests that detect the presence of the bacteria or its toxins. Blood tests are not used for diagnosing C. difficile infections.
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