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    HESI RN EXIT 1 PROCTORED EXAMQuestion 110
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    HESI RN EXIT 1 PROCTORED EXAM
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    The client is a 49-year-old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. 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. Body System Assessment Finding Cardiovascular BP 145/89 mmHg Heart Rate 101 bpm Capillary refill 4 seconds Neurologic Awake and alert Anxious and Restless Respiratory Oxygen saturation 90% Respiratory rate 28bpm Productive cough

    Explanation & Rationale

    O2 saturation: Directly reflects the level of oxygen in the blood. Respiratory rate 28 bpm: Indicates increased effort to obtain oxygen. Anxious, Restless: Neurological signs of inadequate oxygenation. BP 145/89 mmHg: Elevated blood pressure can be a response to hypoxia. Heart Rate 101 bpm: Increased heart rate is a compensatory mechanism for hypoxia.

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