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 D
Explanation
Choice A reason: Dry skin is not a sign of respiratory alkalosis. Respiratory alkalosis is a condition where the blood pH is too high due to excessive loss of carbon dioxide through rapid breathing. Dry skin can be caused by dehydration, cold weather, or skin conditions.
Choice B reason: Diarrhea is not a sign of respiratory alkalosis. Diarrhea is a condition where the stool is loose and watery due to increased intestinal motility or infection. Diarrhea can cause metabolic acidosis, which is a condition where the blood pH is too low due to excessive loss of bicarbonate.
Choice C reason: Abdominal pain is not a sign of respiratory alkalosis. Abdominal pain is a symptom that can have many causes, such as gastritis, appendicitis, or irritable bowel syndrome. Abdominal pain can also cause hyperventilation due to anxiety or discomfort, but it is not a direct result of respiratory alkalosis.
Choice D reason: Hyperventilation is a sign of respiratory alkalosis. Hyperventilation is a condition where the breathing rate is faster than normal, causing excess carbon dioxide to be expelled from the lungs. This lowers the partial pressure of carbon dioxide in the blood, which increases the blood pH and causes alkalosis. Hyperventilation can be caused by anxiety, fever, pain, or lung diseases.
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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