The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

Confusion

Apnea

Cyanosis

Dysrhythmias

Answer and Explanation

The Correct Answer is A

A. Confusion can be an early sign of hypoxia, especially when oxygen delivery to the brain is compromised. Inadequate oxygenation can affect cognitive function and mental status, leading to confusion. This occurs because the brain is highly sensitive to changes in oxygen levels.

B. Apnea refers to the absence of breathing. While severe hypoxia can lead to respiratory arrest and apnea, it is not typically an early manifestation of hypoxia. Early hypoxia is characterized by attempts to increase ventilation to compensate for decreased oxygen levels, rather than complete cessation of breathing.

C. Cyanosis occurs when there is a bluish discoloration of the skin and mucous membranes due to deoxygenated hemoglobin in the blood. Cyanosis is a late sign of hypoxia and usually indicates significant oxygen deprivation. It is not typically seen in early hypoxia stages.

DDysrhythmias (irregular heart rhythms) can occur as a result of hypoxia, especially if the heart muscle is not receiving enough oxygen. However, dysrhythmias are generally considered a later manifestation of hypoxia, as the heart attempts to compensate for decreased oxygen delivery.

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Correct Answer is B

Explanation

B. This is the best response. It demonstrates empathy, active listening, and a willingness to understand the client's emotions. By inviting the client to express their feelings further, the nurse creates an opportunity for therapeutic communication and can better assess how to support the client emotionally.

A. This response dismisses the client's feelings of anger and sadness and may come across as minimizing their emotions. It does not acknowledge the client's current state of distress or provide validation for their feelings.

C. This response expresses empathy and acknowledges the client's feelings, which is important. However, it may seem somewhat passive and could benefit from further exploration or invitation for the client to elaborate on their feelings.

D. This response is dismissive and judgmental. It may make the client feel invalidated or criticized for expressing their emotions, which can further escalate feelings of anger or distress.

Correct Answer is ["16"]

Explanation

Total Volume (ml) / Rate (ml/hr) = Time (hr).

For a client receiving 2 liters of IV fluid at a rate of 125 ml/hr,

Convert liters to milliliters (since 1 liter = 1000 ml, therefore 2 liters = 2000 ml). Then, divide the total volume by the rate: 2000 ml / 125 ml/hr = 16 hours.

So, the nurse should expect the IV fluids to last for 16 hours.

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The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who lost his family in a fire. Upon entering the room, the client states angrily. "I hate this place. No one can help me." The nurse's best response would be:

Correct Answer is B

Explanation

A client is to receive 2 liters of IV fluid at 125 ml/hr. How long should the nurse expect the IV fluids to last? Document number of hours.

Correct Answer is ["16"]

Explanation

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