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 B

Explanation

Choice A reason: Metabolic alkalosis is a condition in which the blood pH is elevated due to an excess of bicarbonate or a loss of acid. It can be caused by vomiting, diuretics, or excessive antacid intake. It is not associated with COPD.

Choice B reason: Respiratory acidosis is a condition in which the blood pH is lowered due to an accumulation of carbon dioxide. It can be caused by hypoventilation, airway obstruction, or lung diseases such as COPD. It is the most common acid-base imbalance in COPD patients.

Choice C reason: Respiratory alkalosis is a condition in which the blood pH is elevated due to a loss of carbon dioxide. It can be caused by hyperventilation, anxiety, fever, or aspirin overdose. It is not common in COPD patients.

Choice D reason: Metabolic acidosis is a condition in which the blood pH is lowered due to an excess of acid or a loss of bicarbonate. It can be caused by diabetic ketoacidosis, renal failure, or lactic acidosis. It is not directly related to COPD.

A. Confirm the client's identity by checking their wristband. B. Provide for the client's privacy by closing the curtains. C. Assist the client into the Sims' position. D. Insert the tip of the enema tubing into the client's rectum.

Correct Answer is A,B,C,D

Explanation

Choice A reason: Confirming the client's identity by checking their wristband is the first step to ensure that the right client receives the right treatment.

Choice B reason: Providing for the client's privacy by closing the curtains is the second step to respect the client's dignity and comfort.

Choice C reason: Assisting the client into the Sims' position is the third step to facilitate the insertion of the enema tubing and the flow of the solution. The Sims' position is a side-lying position with the upper leg flexed and the lower leg straight.

Choice D reason: Inserting the tip of the enema tubing into the client's rectum is the fourth and final step to administer the enema. The nurse should lubricate the tip of the tubing, gently insert it about 3 to 4 inches into the rectum, and release the clamp to allow the solution to flow. The nurse should monitor the client for any signs of discomfort or cramping and adjust the flow rate accordingly.

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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

A nurse is caring for a client who has COPD. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

Correct Answer is B

Explanation

A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

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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?