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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Muscle twitching is a sign of central nervous system oxygen toxicity, which can occur when breathing high concentrations of oxygen under pressure. It can also cause seizures, confusion, and loss of consciousness.

Choice B reason: Facial flushing is not a symptom of oxygen toxicity. It can be caused by other conditions such as fever, allergic reactions, or alcohol consumption.

Choice C reason: Periorbital edema is not a symptom of oxygen toxicity. It can be caused by other conditions such as kidney disease, heart failure, or allergies.

Choice D reason: Metallic taste in mouth is not a symptom of oxygen toxicity. It can be caused by other conditions such as medication side effects, dental problems, or infections.

A. I need to catheterize the stoma several times a day. B. I will need to measure my stoma each week. C. I will always have to wear a pouch. D. I need to cleanse around the stoma with soap and water.

Correct Answer is A

Explanation

Choice A reason: This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.

Choice B reason: This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.

Choice C reason: This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.

Choice D reason: This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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