The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?
Confusion
Apnea
Cyanosis
Dysrhythmias
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1700"]
Explanation
To calculate the time when a new IV bag will be needed, we can divide the total volume left in the bag by the infusion rate.
With 500 ml remaining and an infusion rate of 100 ml per hour, it will take 5 hours for the current bag to be depleted.
Since the report was given at 1200 (which is noon in military time), adding 5 hours brings us to 1700, or 5:00 PM.
Therefore, the nurse should expect to hang a new IV bag at 1700 hours in military time.
Correct Answer is A
Explanation
A. Giving a written warning is a serious disciplinary action that should only be considered after other steps to support and assist the assistant have been taken. It does not promote a supportive or constructive approach to resolving the issue.
B. This option involves the nurse providing guidance and support to the assistant. By acting as a role model, the nurse can demonstrate the correct way to approach the task and provide alternative solutions or techniques. This approach encourages learning and professional development for the assistant.
C. While this may temporarily resolve the issue, it does not address the assistant's competency or provide an opportunity for learning and growth. It may also undermine the assistant's confidence and independence in performing the task.
D. While providing another task might offer another chance for success, it does not directly address the current difficulty with the delegated task. The nurse should focus on addressing the specific challenge at hand before assigning additional tasks.
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