Neurological Question #44

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:
  2. Cyanosis to nail beds and around mouth.
    • Rationale:
  3. Diminished breath sounds and respirations < 12 per minute.
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  4. Restlessness.
    • Rationale:

Overview

Explanation

Restlessness is one of the first signs of oxygen deprivation, even in an unconscious client. The nurse should monitor oxygen levels through oximeter or arterial blood gas results. Decreased heart and blood pressure may not reflect hypoxia, and some clients will have initial hypertensive response first. Respiratory effort and cyanosis are both later signs of hypoxia, and the goal is to monitor for early signs to prevent further complications.

Learning Outcomes

Test Taking Tip

Video Rationale