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The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

A.

Elevated blood pressure

B.

Increased pulse rate

C.

Cyanosis

D.

Restlessness

Answer and Explanation

The Correct Answer is C

A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.  

 

B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.  

 

C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.  

 

D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.


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View Related questions

Correct Answer is B

Explanation

A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.

B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.

C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.

D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.

Correct Answer is D

Explanation

A. An increase in heart rate does not directly affect hemoglobin levels; this option is incorrect.

B. A higher heart rate decreases diastolic filling time, as there is less time for the heart to fill between beats, which can lead to reduced stroke volume.

C. An increased heart rate does not inherently increase stroke volume; in fact, at very high rates, stroke volume can decrease due to reduced filling time.

D. The significant increase in heart rate to 164 beats/min can lead to decreased cardiac output due to compromised diastolic filling and reduced stroke volume.

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