The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

restlessness, confusion, tachycardia.

bradycardia, dyspnea, cyanosis.

hypotension, vomiting, cyanosis.

bradycardia, lethargy, confusion.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Restlessness, confusion, and tachycardia are early signs of hypoxia, indicating inadequate oxygenation.

Choice B rationale: Bradycardia, dyspnea, and cyanosis are more indicative of advanced hypoxia.

Choice C rationale: Hypotension, vomiting, and cyanosis may suggest severe hypoxia or other medical issues but are not typically early signs.

Choice D rationale: Bradycardia, lethargy, and confusion are not typical early signs of hypoxia.

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Correct Answer is B

Explanation

Choice A rationale: Promotion of oxygenation by enhancing air circulation around the wound is not the primary treatment for a "yellow" wound.

Choice B rationale: Removal of nonviable tissue followed by a moist wound dressing is the expected treatment for a wound with yellow color, indicating the presence of slough (nonviable tissue).

Choice C rationale: Use of barrier cream and a foam dressing may be indicated for other types of wounds but may not address the specific issue of nonviable tissue in a "yellow" wound.

Choice D rationale: No treatment is necessary is not appropriate for a wound with evidence of nonviable tissue.

A. inhales slowly to raise the ball to the desired level, and attempts to keep the ball raised for several seconds B. blows into the mouthpiece with a long slow expiration to keep the ball at the base of the spirometer. C. begins breathing with a rapid, forceful inspiration to raise the ball as high as possible. D. exhales slowly to raise the ball to the desired level, and quickly inhales to raise the ball again.

Correct Answer is A

Explanation

Choice A rationale: Inhaling slowly to raise the ball to the desired level and attempting to keep the ball raised for several seconds is the correct technique for using an incentive spirometer.

Choice B rationale: Blowing into the mouthpiece with a long slow expiration is not the correct technique for using an incentive spirometer.

Choice C rationale: Beginning breathing with a rapid, forceful inspiration is not the recommended technique for using an incentive spirometer.

Choice D rationale: Exhaling slowly to raise the ball and quickly inhaling is not the correct technique for using an incentive spirometer.

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The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

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Naxlex Comprehensive Predictor Exams

On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?

Correct Answer is B

Explanation

The nurse knows that teaching about the use of the spirometer incentive is effective when the client seals the lips around the mouthpiece and:

Correct Answer is A

Explanation

The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:

When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a dropdown pressure ulcer.

The nurse recognizes that the most appropriate reason to suction a client is that:

A nurse receives an order for blood, urine, stool and nasal cultures on a client with a high fever. Which prefix describes this order?

A client has had an uncomplicated repair of an inguinal hernia. On the second post- operative day, the client has mildly elevated temperature and general malaise. The nurse recognizes that this is a generalized body response which is common to which phase of healing?

The nurse understands that the major factor affecting oxygenation in a client who has fluid in the lungs is:

The nurse is administering medications to a client who has severe liver damage. Which medications, as ordered below, will avoid the first pass effect? (SELECT ALL THAT APPLY)

The client has had a surgical debridement of a wound, which is starting to heal. In order to further promote healing, this client should be encouraged to consume a balanced diet with emphasis on increased: