A client with chronic lung disease is prescribed 40% oxygen via face mask. Which finding indicates to the nurse that the client is experiencing oxygen toxicity? Select all that apply.

Pink frothy sputum

Substernal discomfort

Nail clubbing

Restlessness

Cyanosis at nail beds

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Pink frothy sputum is a classic sign of pulmonary edema, which can occur as a result of oxygen toxicity. When the alveoli in the lungs fill with fluid, it can lead to this type of sputum. This is a critical indicator that the client is experiencing severe respiratory distress and requires immediate medical attention.

Choice B reason: Substernal discomfort or chest pain is another symptom of oxygen toxicity. This discomfort arises due to the irritation and inflammation of the lung tissues caused by high levels of oxygen. It is essential to monitor and address this symptom promptly to prevent further complications.

Choice C reason: Nail clubbing is typically associated with chronic hypoxia and long-term lung diseases, but it is not an acute indicator of oxygen toxicity. Therefore, it is not relevant in this context.

Choice D reason: Restlessness is a common early sign of hypoxia and can also indicate oxygen toxicity. When the brain does not receive adequate oxygen, it can lead to symptoms such as restlessness, confusion, and agitation. This symptom should be taken seriously and addressed immediately.

Choice E reason: Cyanosis at the nail beds indicates a lack of oxygen in the blood, but it is not specific to oxygen toxicity. It can occur in various conditions where there is inadequate oxygenation, such as chronic obstructive pulmonary disease (COPD) or heart failure.

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Correct Answer is ["A","J"]

Explanation

Intervention: Validate that informed consent has been given by the client.

Reason: Before any invasive procedure, it is crucial to ensure that the client has given informed consent. This means the client understands the procedure, its risks, benefits, and any potential complications. Validating informed consent is a legal and ethical requirement that ensures the client is making an informed decision about their care12.

Assessment: The trachea is shifted away from the midline of the neck.

Reason: A tracheal shift is a critical finding that warrants immediate action. It can indicate a tension pneumothorax, which is a life-threatening condition where air accumulates in the pleural space and causes the lung to collapse. This shift can compromise respiratory function and requires urgent intervention34.

Choice B: Pulse oximetry is 93% on 2 L of oxygen.

Reason: While a pulse oximetry reading of 93% on 2 liters of oxygen is slightly below the normal range (95-100%), it is not immediately life-threatening. However, it does indicate that the client may need further evaluation and monitoring to ensure adequate oxygenation.

Choice C: The client rates pain as 8/10 at the site of the procedure.

Reason: Pain management is important, but an 8/10 pain rating at the procedure site, while significant, does not require immediate action compared to a tracheal shift. Pain can be managed with appropriate analgesics as ordered by the physician.

Choice D: Request an order for pain medication.

Reason: Requesting an order for pain medication is a necessary intervention for managing the client’s pain, but it is not as urgent as addressing a tracheal shift. Pain management should be part of the overall care plan.

Choice E: Measure oxygen saturation before and after a 12-minute walk.

Reason: Measuring oxygen saturation before and after a 12-minute walk is a useful assessment to evaluate the client’s respiratory function and endurance. However, it is not an immediate priority compared to ensuring informed consent and addressing critical findings.

Choice F: Explain the procedure in detail to the client and the family.

Reason: Explaining the procedure in detail to the client and their family is essential for informed consent and reducing anxiety. It ensures that the client understands what to expect and can make an informed decision about their care.

Choice G: Assist the client to the bathroom.

Reason: Assisting the client to the bathroom is a routine nursing intervention that ensures the client’s comfort and dignity. However, it is not a priority compared to addressing critical findings and ensuring informed consent.

Choice H: Discuss all possible complications with the client.

Reason: Discussing all possible complications with the client is part of the informed consent process. It ensures that the client is aware of potential risks and can make an informed decision about their care.

Choice I: A small amount of drainage from the site is noted.

Reason: Noting a small amount of drainage from the site is an important assessment, but it is not as urgent as addressing a tracheal shift. The drainage should be monitored and documented, and any significant changes should be reported to the physician.

A. Encourage dietary intake B. Encourage plenty of fat C. Serve dairy products D. Order a high-fiber diet

Correct Answer is D

Explanation

Order a high-fiber diet

Choice A Reason:

Encourage dietary intake

Encouraging dietary intake is generally important for maintaining nutritional status, but it is not specific to the preparation for a barium enema. The preparation for a barium enema typically involves dietary restrictions to ensure the colon is clear for the procedure. Therefore, this choice is not correct.

Choice B Reason:

Encourage plenty of fat

Encouraging plenty of fat is not appropriate for the preparation of a barium enema. High-fat foods can slow down the digestive process and may interfere with the clarity of the images obtained during the procedure. Therefore, this choice is not correct.

Choice C Reason:

Serve dairy products

Serving dairy products is not recommended before a barium enema. Dairy products can cause gas and bloating, which can interfere with the procedure. Additionally, some patients may be lactose intolerant, which can further complicate the preparation. Therefore, this choice is not correct.

Choice D Reason:

Order a high-fiber diet

Ordering a high-fiber diet is the correct choice. A high-fiber diet helps to clear the intestines by promoting bowel movements. This is important for ensuring that the colon is empty and clear for the barium enema, which allows for better imaging and more accurate results.

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A client with chronic lung disease is prescribed 40% oxygen via face mask. Which finding indicates to the nurse that the client is experiencing oxygen toxicity? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","J"]

Explanation

A nurse is preparing a client with Crohn’s disease for a barium enema. What should the nurse do the day before the test?

Correct Answer is D

Explanation

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