Practice Question
The nurse is assessing a client for signs of hypoxia. Which findings should the nurse expect? (Select All that Apply.)
Answer Choices:
Correct Answer:
Tachypnea
Rationale:
✅ Tachypnea
✴ Definition: Tachypnea refers to an abnormally increased respiratory rate — typically more than 20 breaths per minute in adults.
✴ Reason: When the body experiences low oxygen levels (hypoxia), the medulla oblongata (respiratory control center) stimulates faster breathing to increase oxygen intake and remove excess carbon dioxide.
✴ Physiological Response: This compensatory mechanism aims to improve oxygen delivery to vital organs, especially the brain and heart, which are highly oxygen-dependent.
✴ Clinical Significance: Persistent tachypnea can quickly progress to respiratory distress or fatigue if the underlying cause of hypoxia (e.g., lung disease, airway obstruction) is not corrected.
✴ Nursing Action: The nurse should monitor respiratory rate closely, observe for accessory muscle use, and provide oxygen therapy as prescribed to prevent further deterioration.
✅ Cyanosis
💠 Definition: Cyanosis is a bluish discoloration of the skin, lips, and nail beds caused by reduced oxygenated hemoglobin in the blood.
💠 Pathophysiology: It develops when oxygen saturation falls below approximately 85%, indicating inadequate oxygen transport to the peripheral tissues.
💠 Types: Central cyanosis (seen on mucous membranes and tongue) indicates systemic oxygen deficiency, while peripheral cyanosis (on fingertips or toes) results from poor circulation or vasoconstriction.
💠 Clinical Importance: Cyanosis is a late and serious sign of hypoxia, suggesting that oxygen levels are critically low and tissues are not receiving sufficient oxygen.
💠 Nursing Action: The nurse should initiate emergency oxygen therapy, assess airway patency, and promptly notify the healthcare provider for potential respiratory compromise.
✅ Restlessness
🔷 Definition: Restlessness is a behavioral manifestation of early hypoxia due to insufficient oxygen supply to the brain.
🔷 Neurological Basis: The brain is highly sensitive to hypoxemia, and even slight oxygen deprivation can cause altered mental status, anxiety, or agitation.
🔷 Early Indicator: Restlessness often appears before cyanosis or severe dyspnea, making it a crucial early warning sign for the nurse to act upon.
🔷 Clinical Implication: Persistent restlessness may progress to confusion, irritability, or lethargy, indicating worsening cerebral hypoxia.
🔷 Nursing Action: The nurse should assess oxygen saturation (SpO₂) immediately, provide supplemental oxygen, and ensure that the airway remains open to prevent respiratory arrest.
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This question is from PN-CUSTOM GAS EXCHANGE AND OXYGENATION CLONED ASSESSMENT 2 which contains 50 questions.
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PN-CUSTOM GAS EXCHANGE AND OXYGENATION CLONED ASSESSMENT 2
50 Questions
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- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Medical-Surgical
- Answer Choices: 5