Practice Question
The nurse is assessing a patient for late hypoxia. Which of the following does the nurse recognize as symptoms of late hypoxia? (Select All That Apply)
Answer Choices:
Correct Answer:
Dyspnea
Rationale:
✅ Dyspnea
🟦 Dyspnea is a major indicator that the respiratory system is no longer able to maintain adequate oxygen exchange as hypoxia progresses from early to late stages.
🟦 In late hypoxia, alveolar gas exchange becomes severely impaired, causing oxygen levels to drop and carbon dioxide to accumulate, which triggers an intense sense of breathlessness.
🟦 As oxygen delivery to vital organs decreases, the body attempts to compensate by increasing respiratory effort, often resulting in visibly labored breathing, use of accessory muscles, and rapid respiratory fatigue.
🟦 Recognizing dyspnea as a late sign is crucial because it signals impending respiratory failure, requiring immediate oxygenation support and possibly advanced airway management.
✅ Bradycardia
🟩 Bradycardia is a late and ominous sign of hypoxia indicating that compensatory mechanisms have failed and the cardiac muscle is no longer receiving enough oxygen to maintain function.
🟩 Earlier in hypoxia, the heart typically increases its rate (tachycardia) to circulate limited oxygen more rapidly, but as oxygen delivery continues to fall, myocardial tissue becomes depressed and the heart rate slows.
🟩 This slowing reflects declining cardiac output and reduced perfusion to the brain and other vital organs, placing the patient at high risk for cardiac arrest.
🟩 Immediate intervention is critical, as bradycardia in the context of hypoxia is a precursor to lethal arrhythmias and circulatory collapse.
✅ Extreme restlessness
🟫 Extreme restlessness is an important neurological manifestation of severe hypoxia because brain tissue is extremely sensitive to low oxygen levels.
🟫 As cerebral oxygenation declines, neurons experience metabolic stress, leading to agitation, confusion, anxiety, and inability to remain still.
🟫 This restless behavior reflects early cerebral dysfunction, which—if unrecognized—may progress to loss of consciousness, seizures, or irreversible brain injury.
🟫 Nurses rely on this behavioral change as a red-flag indicator that oxygenation is critically low and immediate intervention is required to prevent neurological compromise.
❌ Incorrect Options
❌ Increased appetite
— Hypoxia reduces appetite; the body prioritizes oxygenation over digestion.
❌ Brisk capillary refill
— Late hypoxia causes poor perfusion, leading to delayed, not brisk, capillary refill.
Want to practice more questions like this?
This question is from EXAMPLIFY NUR 204 Fa 2025 EXAM 3 which contains 48 questions.
More Questions from This Exam
A patient is admitted to the hospital and the nurse auscultates wheezing. Which of the following sounds would the nurse hear to determine wheezing?
Answer Choices:
Where would the nurse locate the point of maximal impulse?
Answer Choices:
Assess the patient's popliteal pulses, what area of the body should the nurse palpate?
Answer Choices:
A patient reports frequent urination at night. How should the nurse document this finding?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 5