The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?
Elevated blood pressure
Increased pulse rate
Cyanosis
Restlessness
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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Correct Answer is ["A","C","D","E"]
Explanation
A. Communication signs for airborne precautions are necessary to inform staff and visitors about the required precautions for TB, which is spread via airborne transmission.
B. A surgical mask is not adequate for TB; instead, an N95 respirator is required to filter out the airborne particles effectively.
C. The N95 respirator, gown, gloves, and eyewear are essential personal protective equipment for caring for a patient with tuberculosis. The N95 respirator specifically protects against inhaling infectious particles.
D. Negative-pressure airflow in the room is critical for tuberculosis patients to prevent airborne contaminants from spreading to other areas of the facility.
E. A private room is required to isolate the patient and reduce the risk of transmission to other patients and staff.
F. A communication sign for droplet precautions is not applicable as tuberculosis is primarily transmitted via airborne routes, not droplet transmission.
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.