A nurse is assisting with the care of a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?
Respiratory rate 28/min
Pink mucous membranes
Heart rate 110/min
Restlessness
The Correct Answer is B
Choice A reason: Respiratory rate 28/min is not a sign of effective oxygen therapy, as it indicates tachypnea, which is a rapid breathing rate. Tachypnea can be caused by hypoxia, anxiety, fever, or pain.
Choice B reason: Pink mucous membranes are a sign of effective oxygen therapy, as they indicate adequate oxygenation of the tissues. Pink mucous membranes are a normal finding, while pale, cyanotic, or jaundiced mucous membranes can indicate hypoxia or other problems.
Choice C reason: Heart rate 110/min is not a sign of effective oxygen therapy, as it indicates tachycardia, which is a rapid heart rate. Tachycardia can be caused by hypoxia, stress, dehydration, or infection.
Choice D reason: Restlessness is not a sign of effective oxygen therapy, as it indicates agitation, anxiety, or discomfort. Restlessness can be caused by hypoxia, pain, or medication side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Rigid abdomen is not a sign of diarrhea, but rather a sign of peritonitis, which is an inflammation of the abdominal lining. Peritonitis can be caused by a perforated ulcer, appendicitis, or diverticulitis.
Choice B reason: Dehydration is a sign of diarrhea, as it indicates a loss of fluid and electrolytes from the body. Dehydration can cause symptoms such as dry mouth, thirst, decreased urine output, sunken eyes, and low blood pressure.
Choice C reason: Hypothermia is not a sign of diarrhea, but rather a sign of low body temperature. Hypothermia can be caused by exposure to cold, shock, or infection.
Choice D reason: Decreased bowel sounds are not a sign of diarrhea, but rather a sign of ileus, which is a lack of intestinal activity. Ileus can be caused by surgery, medication, or obstruction.
Correct Answer is C
Explanation
Choice A reason: Shaking the inhaler well before using it is a correct action for the client to take, as it helps to mix the medication and the propellant. However, it is not the best answer, as it is a general instruction that applies to most inhalers, not a specific one that indicates an understanding of the teaching.
Choice B reason: Holding the breath for 10 seconds after inhaling the medication is a correct action for the client to take, as it helps to keep the medication in the lungs and improve its absorption. However, it is not the best answer, as it is a general instruction that applies to most inhalers, not a specific one that indicates an understanding of the teaching.
Choice C reason: Rinsing the mouth with water after using the inhaler is the best answer, as it indicates an understanding of the teaching. Rinsing the mouth with water helps to prevent oral thrush, a fungal infection that can occur as a side effect of some inhalers, especially those that contain steroids.
Choice D reason: Waiting 30 seconds between each puff of the inhaler is not a correct action for the client to take, as it can reduce the effectiveness of the medication. The client should wait at least one minute between each puff of the inhaler, unless instructed otherwise by the provider.
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