Question

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

a) Increased heart rate
b) Clear breath sounds
c) Cyanosis of the lips
d) Systolic blood pressure elevation

Answer 1

Cyanosis of the lips is a direct indication of hypoxia, which is characterized by a deficient level of oxygen in the body tissues. Decreased heart rate, systolic blood pressure elevation, and cyanosis are signs to be monitored during a tracheostomy tube suctioning to assess for hypoxia.

Step-by-step explanation:

When assessing a client who is having their tracheostomy tube suctioned, the nurse should be attentive to indicators of hypoxia. The findings that could indicate the client is experiencing hypoxia include increased heart rate, cyanosis of the lips, and potentially systolic blood pressure elevation. However, the most direct indication of hypoxia among the options provided is cyanosis of the lips, as this is a visible sign of reduced oxygen saturation in the blood, causing the skin and mucous membranes to appear blue or purple.

Another method to assess oxygenation is through the use of a pulse oximeter, which measures the oxygen level in the blood and provides immediate feedback if a client's airways are being obstructed and affecting their oxygen levels. Situations that lead to hyperpnea or increased respiratory effort, such as physical exercise, do not necessarily result in hypoxia, as the body appropriately adjusts oxygen delivery and carbon dioxide clearance.