Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.

Cardiovascular - Capillary refill 4 seconds - A prolonged capillary refill time indicates poor peripheral perfusion, which can be a sign of hypoxia. Hypoxia can lead to reduced oxygen delivery to the tissues, resulting in delayed capillary refill. Respiratory - Oxygen saturation 90% on room air - An oxygen saturation level of 90% is below the normal range (95-100%) and indicates that the blood is not adequately oxygenated, which is a direct sign of hypoxia. - Respiratory rate 28 breaths/minute - An elevated respiratory rate (tachypnea) is a common compensatory mechanism in response to hypoxia. The body attempts to increase oxygen intake and carbon dioxide expulsion by breathing more rapidly. Neurological - Anxious - Anxiety can be a symptom of hypoxia. When the brain and other vital organs do not receive enough oxygen, it can trigger a sense of anxiety and restlessness as part of the body's alarm system. - Restless - Restlessness is another common symptom of hypoxia. It occurs because the body is trying to compensate for the lack of oxygen, leading to increased agitation and an inability to remain calm. Rationales for the Incorrect Choices: - Cardiovascular - Heart rate 101 beats/minute: While an elevated heart rate can be a compensatory response to hypoxia, it alone does not directly indicate hypoxia. - Blood pressure 145/89 mm Hg: Elevated blood pressure is not a direct indicator of hypoxia and can be influenced by various factors including anxiety and pain. - Respiratory - Productive cough: A productive cough suggests respiratory infection or inflammation but does not directly measure oxygenation status or indicate hypoxia. - Neurological - Awake and alert: Being awake and alert indicates normal mental status and does not suggest hypoxia. Hypoxia typically affects cognitive function, leading to confusion or decreased level of consciousness in more severe cases.