Question

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse that the client is experiencing hypoxia?

A) Increased heart rate.
B) Pink-tinged secretions.
C) Respiratory rate of 20 breaths per minute.
D) Clear breath sounds.

Answer 1

An increased heart rate is a clinical indicator of hypoxia. Pink-tinged secretions and a respiratory rate of 20 breaths per minute do not necessarily suggest hypoxia, and clear breath sounds are generally a positive finding.

Step-by-step explanation:

When assessing if a client is experiencing hypoxia while suctioning their tracheostomy tube, the nurse should look for signs that indicate a lack of adequate oxygenation. An increased heart rate is a key indicator of hypoxia. The body often responds to low oxygen levels by increasing the heart rate to pump more blood, and hopefully more oxygen, to the tissues.

Pink-tinged secretions may indicate blood, but not necessarily hypoxia. A respiratory rate of 20 breaths per minute can be considered within the normal range for an adult, and clear breath sounds are a positive sign that the airways are not obstructed. However, in the context of hypoxia, the clinical findings suggestive of inadequate oxygenation would include a rapid heart rate, possibly changes in color (like cyanosis), altered alertness, or signs of respiratory difficulty such as shortness of breath.

Answer 2

An increased heart rate should indicate to the nurse that the client is experiencing hypoxia, as the body tries to deliver more oxygen to tissues; pink-tinged secretions, normal respiratory rate, and clear breath sounds are less indicative of hypoxia.

Step-by-step explanation:

The correct answer to the question of which finding should indicate to the nurse that the client is experiencing hypoxia while suctioning the client's tracheostomy tube is A) Increased heart rate. Hypoxia refers to a state in which there is an insufficient level of oxygen reaching the tissues. An increased heart rate is a compensatory mechanism the body uses to try to deliver more oxygen to tissues when there is concern for hypoxia. The pulse oximeter measures the oxygen saturation of the blood, alerting healthcare providers to any discrepancies between what should be a normal oxygen level (typically 95-100% saturation) and what is being measured. The other options - B) Pink-tinged secretions, C) Respiratory rate of 20 breaths per minute, D) Clear breath sounds - do not directly indicate hypoxia. Pink-tinged secretions can indicate bleeding, a respiratory rate of 20 breaths per minute is within normal range, and clear breath sounds suggest that the airways are free from significant obstruction or fluid accumulation.