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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: A buffalo hump is a characteristic sign of Cushing’s syndrome. It refers to the accumulation of fat on the back of the neck and shoulders. This symptom occurs due to the excessive production of cortisol, which leads to abnormal fat distribution in the body.
Choice B reason: Moon face is another hallmark of Cushing’s syndrome. It describes the rounding and fullness of the face, which results from fat deposits. This symptom is also caused by prolonged exposure to high levels of cortisol.
Choice C reason: Hypertension, or high blood pressure, is commonly associated with Cushing’s syndrome. Cortisol increases blood pressure by enhancing the sensitivity of blood vessels to catecholamines and by promoting sodium and water retention.
Choice D reason: Purple striations, or stretch marks, are often seen in individuals with Cushing’s syndrome. These marks typically appear on the abdomen, thighs, breasts, and arms. They result from the thinning of the skin and the breakdown of collagen due to elevated cortisol levels.
Choice E reason: Tremors are not typically associated with Cushing’s syndrome. While Cushing’s syndrome can cause a variety of symptoms, tremors are more commonly linked to other conditions such as hyperthyroidism or neurological disorders.
Correct Answer is B
Explanation
Choice A reason: Consuming a high-protein diet is not typically recommended for clients with hepatitis B. While protein is essential for overall health, excessive protein intake can put additional strain on the liver. Instead, a balanced diet with adequate carbohydrates, fruits, and vegetables is advised to support liver function.
Choice B reason: Resting frequently throughout the day is crucial for clients with hepatitis B. The liver is responsible for many vital functions, including detoxification, protein synthesis, and the production of biochemicals necessary for digestion. When the liver is inflamed or damaged, as in hepatitis B, it needs ample rest to recover and function properly.
Choice C reason: Clients with hepatitis B should not donate blood. Hepatitis B is a bloodborne virus, and donating blood can transmit the infection to others. Blood donation guidelines strictly prohibit individuals with hepatitis B from donating blood, regardless of the time elapsed since completing medication.
Choice D reason: Taking acetaminophen every 4 hours for discomfort is not advisable for clients with hepatitis B. Acetaminophen is metabolized by the liver, and excessive use can lead to liver damage. Clients with liver conditions should use acetaminophen sparingly and under medical supervision to avoid exacerbating liver damage.
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