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 ["A","D","E"]
Explanation
Choice A: Iron supplements are used to treat iron-deficiency anemia, but they can also reduce the motility of the gastrointestinal tract and make the stools harder and drier¹². This can lead to difficulty in passing stools and increased straining.
Choice B: Magnesium-containing antacids are used to treat heartburn and acid reflux, but they can also have a laxative effect and cause diarrhea¹³. This is because magnesium draws water into the intestines and stimulates bowel movements.
Choice C: Antibiotics are used to treat bacterial infections, but they can also disrupt the normal flora of the gut and cause diarrhea¹⁴. This is because antibiotics can kill the beneficial bacteria that help digest food and prevent the overgrowth of harmful bacteria that cause inflammation and infection.
Choice D: Anticholinergics/antispasmodics are used to treat overactive bladder, irritable bowel syndrome, and other conditions that involve muscle spasms in the gut, but they can also slow down the movement of the intestines and relax the muscles that help push the stools out¹ . This can lead to reduced frequency and difficulty in defecation.
Choice E: Opioid narcotics are used to treat moderate to severe pain, but they can also block the signals from the brain to the gut and inhibit the contraction of the intestinal muscles¹ . This can lead to decreased bowel activity and accumulation of hard and dry stools.
Correct Answer is D
Explanation
Choice A reason: You should not expect your stoma to be a purple color. A purple stoma indicates ischemia or necrosis, which are serious complications that require immediate medical attention. A healthy stoma should be pink or red and moist.
Choice B reason: Your colostomy will produce formed stool, depending on the location of the colostomy. A sigmoid colostomy is located in the lower part of the large intestine, where most of the water is absorbed from the stool. Therefore, the stool from a sigmoid colostomy will be more solid and regular than from other types of colostomies.
Choice C reason: The end of the stoma will not be painful after this procedure. The stoma is made from the lining of the intestine, which does not have nerve endings that sense pain. However, the skin around the stoma may be sore or irritated from the surgery or the appliance.
Choice D reason: You will have a stoma in your left lower abdomen. A sigmoid colostomy is created by bringing the end of the sigmoid colon, which is the last segment of the large intestine, through an opening in the left lower quadrant of the abdomen. The stoma is then attached to the skin and covered with an appliance that collects the stool.
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