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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. Multipersonal connectedness involves relationships with multiple people, which is not the focus of the nurse-patient connection in spiritual care.

B. Transpersonal connectedness refers to a connection that goes beyond the physical and mental levels, fostering a deeper spiritual relationship between the nurse and the patient, often characterized by empathy and understanding.

C. Interpersonal connectedness describes the relationship between individuals, focusing on social and emotional interactions, but does not encompass the spiritual dimension.

D. Intrapersonal connectedness relates to an individual's self-awareness and inner thoughts, not the connection with another person in a spiritual context.

Correct Answer is C

Explanation

A. While monitoring cardiac output can provide insights into heart function, it does not directly determine the presence of dysrhythmias.

B. Peripheral extremity circulation is influenced by cardiac output but is not the primary focus of monitoring it.

C. Cardiac output is essential for determining the heart's ability to meet the body's oxygenation requirements; low cardiac output can lead to inadequate oxygen delivery.

D. Ventilation status refers to the respiratory function and is not directly assessed through cardiac output measurements.

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