Medical Surgical Oxygen Delivery & Hypoxemia #2

Question

A nurse caring for a client would recognize which sign as an early indicator of hypoxia?

Answers

  1. Paradoxical breathing with tachycardia.
    • Rationale:

      This answer is correct because in early hypoxia, the body will be compensated with paradoxical breathing and a high heart rate because the body is working hard for oxygen. You may see the client use accessory muscles or tripoding to help breathing efforts. The respiratory rate will increase, as well as the blood pressure.

  2. Cyanosis with bradycardia.
    • Rationale:

      This answer is not correct because these are late signs of hypoxia. This happens when the body no longer can compensate. As the body lacks oxygen, the client may turn a bluish color and the vital signs slow down.

  3. Confusion with hypotension.
    • Rationale:

      This answer is not correct because confusion with hypotension occurs with low blood pressure and orthostatic hypotension. This can be caused from dehydration, medications, or thyroid disease.

  4. Cold and clammy with tachycardia.
    • Rationale:

      This answer is not correct because these are signs of shock. With shock, the blood pressure will go down and the heart rate will go up, but will be weak. There will be rapid and shallow breathing and dizziness or weakness.

Overview

Early signs of hypoxia are mental status changes, restlessness, agitation, and confusion. Vital signs will be up: High respiratory rate, high pulse, and high blood pressure.

Explanation

Learning Outcomes

Hypoxia is loss of oxygen below 80%. In early hypoxia, the first noticeable sign will be a change in mental status that might include restlessness, agitation, or confusion. The body will start to compensate for the loss of oxygen. The heart will work harder for oxygen, causing the blood pressure to go up and the heart rate to increase. The client will use accessory muscles to help them breathe. Tripoding or paradoxical breathing patterns may also be seen.

Test Taking Tip

Think about what the body will do during early signs of hypoxia….it will compensate. Think about what is involved when the body compensates for a loss of oxygen.

Video Rationale