The nurse instructs the client and family to observe for client hypoxia during home oxygen therapy. Which is the most important clinical indicator of hypoxia that the nurse instructs the family to monitor?
1. Confusion
2. Dusky lips
3. Tachypnea
4. Restlessness
2
2. The nurse instructs the client and family to monitor for dusky lips, nail beds, or skin as an indication of hypoxia and to call for emergency help if duskiness develops because it is a late sign of hypoxia and potentially indicates that the hypoxia is severe or has persisted for a significant time.
1. Confusion, increased respiratory rate, and restlessness are clinical indicators con-sistent for hypoxia but occur earlier than duskiness. The client with dusky lips should have exhibited these assessment findings initially after decreased oxygenation.
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