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.

Choice A reason:

Elevating the head of the client’s bed can help reduce blood pressure slightly by promoting venous return and decreasing intracranial pressure. However, this action alone is not sufficient to address the severe hypertension (254/139 mm Hg) the client is experiencing. Immediate medical intervention is required to prevent complications such as stroke, heart attack, or organ damage.

Choice B reason:

Contacting the Rapid Response Team is the highest priority action. The Rapid Response Team is trained to handle critical situations and can provide immediate interventions to stabilize the client’s condition. Severe hypertension at this level requires urgent medical attention to prevent life-threatening complications. The team can administer medications to lower blood pressure quickly and monitor the client closely.

Choice C reason:

Telling the client to report vision changes is important because vision changes can indicate hypertensive retinopathy or increased intracranial pressure. However, this action is not the immediate priority. The client’s blood pressure needs to be controlled urgently to prevent further complications.

Choice D reason:

Inserting a peripheral IV is necessary for administering medications and fluids. While this is an important step, it should follow the immediate action of contacting the Rapid Response Team. The team can then use the IV access to administer antihypertensive medications promptly.

Choice E reason:

Initiating seizure precautions is important because severe hypertension can lead to seizures. However, this action is not the first priority. The primary focus should be on stabilizing the client’s blood pressure through immediate medical intervention.

Choice A: Formed stool in collection pouch

Formed stool in the collection pouch is not expected in an ileostomy. The output from an ileostomy is typically liquid to semi-liquid because the ileum does not absorb as much water as the colon. If formed stool is present, it may indicate a blockage or other issue that needs to be addressed.

Choice B: Stoma is edematous and bleeding

An edematous and bleeding stoma is not a normal finding and may indicate complications such as infection, trauma, or poor stoma care. The stoma should be moist and pink, but not swollen or bleeding. Persistent bleeding or significant edema should be reported to a healthcare provider immediately.

Choice C: Stoma is pink and shiny

A pink and shiny stoma is a sign that the ileostomy is functioning well. This indicates good blood flow and healthy tissue. The stoma should always appear moist and pink, similar to the inside of the mouth. Any deviation from this appearance, such as a pale, dark, or dry stoma, should be evaluated by a healthcare professional.

Choice D: Skin excoriation around the stoma

Skin excoriation around the stoma is not a normal finding and suggests that the skin is being irritated by the stoma output or the ostomy appliance. Proper skin care and fitting of the ostomy appliance are essential to prevent skin breakdown. If excoriation occurs, it should be treated promptly to prevent further complications.

Choice E: Mucus liquid flows from the stoma

Mucus liquid flowing from the stoma is expected in an ileostomy. The output is typically liquid to semi-liquid and may contain mucus, which is normal for the small intestine. This type of output indicates that the ileostomy is functioning as intended.