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Patient Data

Exhibits

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. At least one finding could be indicated for each system.

Body System

Assessment Finding

Neurological

Restless

Awake and alert

Anxious

Respiratory

Respiratory rate 28 breaths/minute

Oxygen Saturation 90% on room air Productive cough

Cardiovascular

Heart rate 101 beats/minute Capillary refill 4 seconds

Blood pressure 145/89 mm Hg

Restless

Awake and alert

Anxious

Respiratory rate 28 breaths/minute

Oxygen Saturation 90% on room air

Productive cough

Heart rate 101 beats/minute

Capillary refill 4 seconds

Blood pressure 145/89 mm Hg

Answer and Explanation

The Correct Answer is ["A","C","D","E","G"]

Neurological: Restlessness and anxiety can both be symptoms of hypoxia due to the brain's sensitivity to changes in oxygen levels.

Respiratory: Low oxygen saturation directly indicates hypoxia, and an increased respiratory rate can be a compensatory response to low oxygen levels.

Cardiovascular: Elevated heart rate can be a compensatory mechanism for hypoxia, and delayed capillary refill may indicate poor perfusion related to low oxygen levels.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Decreasing expiratory pressure might not directly address the elevated PaCO2 and low pH.

B. Increasing tidal volume may help, but it’s more critical to address the ventilation rate first.

C. Increasing the rate of ventilation will help blow off more CO2, correcting the respiratory acidosis (elevated PaCO2 and low pH).

D. Decreasing expiratory flow time is less relevant than adjusting ventilation rates in this scenario.

A. Assess the client's ability to communicate with the other staff members. B. Establish a structured routine for the client to follow. C. Arrange a meeting with the family to discuss the client's situation. D. Administer the client's antidepressant medication as prescribed.

Correct Answer is B

Explanation

A. Assessing the client's ability to communicate is important but not the first step in addressing the immediate concerns related to depression.

B. Establishing a structured routine helps provide stability and encourages engagement in daily activities, which is essential for managing depression.

C. Arranging a meeting with the family is important for support but does not immediately address the client’s current refusal to eat or bathe.

D. Administering medication is important but should follow the implementation of supportive measures like establishing a routine that can improve the client's overall engagement and well-being.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Correct Answer is B

Explanation

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