Author Question: It is suspected that the client's oxygenation status is deteriorating. The nurse is aware that which ... (Read 31 times)

jilianpiloj · **on:** Jul 22, 2018

It is suspected that the client's oxygenation status is deteriorating. The nurse is aware that which abnormal assessment finding represents the most serious indication of the client's decreased ox-ygenation?

a. Poor skin turgor
b. Clubbing of the nails
c. Central cyanosis
d. Pursed-lip breathing

Question 2

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding?

a. Glomerular filtration rate of 20 mL/min
b. Urine output of 80 mL/hr
c. pH of 6.4
d. Protein level of 2 mg/100 mL

bob · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Central cyanosis is the most serious finding because it indicates hypoxemia.
Poor skin turgor indicates dehydration. It is not an indication of the client's decreased oxygena-tion.
Clubbing of the nails is found in clients with prolonged oxygen deficiency, endocarditis, and congenital heart defects. It is a change that occurs over time, and is not an indication of the cli-ent's current deterioration in oxygenation status.
Pursed-lip breathing is used to slow expiratory flow. It is not the most serious indication of a client's decreased oxygenation.

Answer to Question 2

A
Normal glomerular filtration rate should be around 125 mL/min; a severe decrease in renal perfusion could indicate a life-threatening problem such as shock or dehydration. Normal urine output is 1000 to 2000 mL/day; an output of 30 mL/hr or less for 2 or more hours would be cause for concern. The normal pH of urine is between 4.6 and 8.0 . Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease.