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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. It is not necessary to keep the infant home from daycare unless the infant has a fever or other signs of illness.
B. Applying a cool pack to the injection site can help reduce discomfort and swelling.
C. Mild fever after vaccinations is common and not typically serious, but high or persistent fever should be reported.
D. Aspirin should not be given to children due to the risk of Reye's syndrome. Acetaminophen or ibuprofen (for infants older than 6 months) are safer alternatives for reducing fever and discomfort.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}
Explanation
Bruises in various stages of healing: This often indicates physical abuse, as it suggests trauma or injury from external force.
Over-sedation: This could be indicative of physical abuse if it is intentional or misuse of medications.
Depression or withdrawn behavior: These can be signs of neglect, as they may result from a lack of emotional support or social interaction.
Leaving an older adult in a public space: This is a clear indicator of abandonment, as it shows neglect of the individual's safety and well-being.
Untreated pressure injuries: These are signs of neglect, reflecting a failure to provide adequate care and prevent injuries.
Poor personal hygiene: Often a result of neglect, indicating a lack of attention to the individual's basic needs and self-care.
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