Difficulty: Medium
Average Score: 87%
Simulated
When assessing a client with early impairment of oxygen perfusion, such as a pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
Correct answer
C
Rationale
When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.