A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?
Metallic taste in mouth
Facial flushing
Muscle twitching
Periorbital edema
The Correct Answer is C
A. Metallic taste in the mouth:
This is not a typical finding of oxygen toxicity. Metallic taste may be associated with other factors but is not a specific indicator of oxygen toxicity.
B. Facial flushing:
Facial flushing is not a typical finding in oxygen toxicity. It is more commonly associated with other conditions, such as certain allergic reactions or vasodilation.
C. Muscle twitching
Muscle twitching, also known as myoclonus, is a recognized symptom of central nervous system oxygen toxicity. High concentrations of oxygen, particularly at increased pressures, can cause neurotoxic effects leading to muscle twitching, dizziness, and even convulsions.
D. Periorbital edema:
Periorbital edema is not a common manifestation of oxygen toxicity. It is more commonly associated with conditions related to fluid balance or kidney function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teaching a client insulin injection technique.
Licensed practical nurses (LPNs) are trained to provide direct patient care, including the administration of medications and patient education. Teaching a client insulin injection technique falls within the scope of practice for an LPN.
B. Evaluating changes to a client’s pressure ulcer:
Assessing and evaluating changes in a client's condition, including pressure ulcers, involves clinical judgment and interpretation of findings, tasks typically performed by an RN.
C. Admission assessment of a new client:
Conducting comprehensive assessments, especially for new admissions, requires a higher level of nursing assessment skills and is generally within the scope of practice for an RN.
D. Scheduling a diagnostic study for a client:
The task of scheduling diagnostic studies involves organizational and administrative skills. RNs often handle coordination of care, including scheduling, as part of their responsibilities.
Correct Answer is B
Explanation
A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.
B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.
C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.
D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.
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