Medical Surgical Assessment & Lung sounds #3

Question

The nurse is caring for an unconscious client and is concerned about early warning signs of hypoxia after observing which characteristic of early hypoxia?

Answers

  1. Decline in blood pressure and pulse.
    • Rationale:

      This answer is not correct because decreased heart and blood pressure may not reflect hypoxia, and some clients will have an initial hypertensive response. Mental status changes are the best indicators of hypoxemia and hypoxia.

  2. Cyanosis to nail beds and around the mouth.
    • Rationale:

      This answer is not correct because cyanosis is a very late sign of hypoxia, and the goal is to monitor for early signs to prevent further complications.

  3. Diminished breath sounds and respirations < 12 per minute.
    • Rationale:

      This answer is not correct because a significant decline in respiratory effort is a late sign of hypoxia. The nurse should assess for early indicators of hypoxia including mental status changes such as restlessness and agitation.

  4. Restlessness and agitation.
    • Rationale:

      This answer is correct because restlessness and agitation are among the earliest signs of oxygen deprivation, even in an unconscious client. The nurse should consider and assess for additional signs of hypoxemia when any mental status change is noted in an at risk client.

Overview

The focus of this question is determining an early warning sign that a client is experiencing hypoxia. Mental status changes are among the earliest indicators of hypoxemia and hypoxia.

Explanation

Learning Outcomes

The central nervous system is very sensitive to ischemia and hypoxemia. When clients become hypoxemic, the central nervous system is one of the earliest systems to be affected. Mental status changes of any kind are one the earliest indicators of hypoxemia and include restlessness, agitation, or confusion. Any change in a client’s baseline mental status should be addressed by the nurse including a focused respiratory assessment.

Test Taking Tip

Mental status changes are always considered the earliest of indicators that a client is becoming hypoxemic and should always be investigated further by the nurse.

Video Rationale