A nurse is assisting with the care of a patient who is receiving supplemental oxygen for hypoxia.
Which of the following findings should the nurse identify as an indication that the intervention was effective?
Respiratory rate 28/min.
Pink mucous membranes.
Heart rate 110/min.
Restlessness.
Restlessness.
The Correct Answer is B
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It causes metabolic, respiratory, and renal responses, producing characteristic symptoms. One of the manifestations of metabolic alkalosis is cardiovascular abnormalities, such as atrial tachycardia. Therefore, placing the patient on continuous cardiac monitoring is a necessary action to assess the patient’s heart rate and rhythm and detect any abnormalities early.
Choice B rationale:
Insulin is not typically used in the treatment of metabolic alkalosis. Insulin is a hormone that regulates blood sugar levels. It’s not directly related to the body’s acid-base balance. Therefore, obtaining a prescription for insulin for the patient would not be a relevant action in this case.
Choice C rationale:
Administering sodium bicarbonate to a patient with metabolic alkalosis would not be appropriate. Sodium bicarbonate is a base and is often used to treat metabolic acidosis, a condition characterized by an excess of acid in the body. Giving sodium bicarbonate to a patient with metabolic alkalosis, a condition characterized by an excess of base in the body, could potentially worsen the patient’s condition.
Choice D rationale:
Having the patient breathe into a paper bag is a common treatment for respiratory alkalosis, not metabolic alkalosis.
Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide in the blood. Breathing into a paper bag helps to increase the amount of carbon dioxide the person inhales, helping to restore the acid-base balance. However, metabolic alkalosis is not caused by hyperventilation, so this treatment
Correct Answer is A
Explanation
Choice A rationale:
Iron supplements Iron supplements are commonly used to treat or prevent iron deficiency anemia. While beneficial in relieving iron deficiency, iron pills can cause side effects like constipation, diarrhea, nausea, vomiting, dark stools, stomach cramps, and a metallic taste. However, constipation is not the primary side effect of iron supplements.
Choice B rationale:
Magnesium-containing antacids Magnesium-containing antacids are used to relieve the symptoms of gastroesophageal reflux disease (GERD), heartburn, or indigestion. By neutralizing stomach acid, antacids relieve symptoms such as burning behind the breast bone or throat area caused by acid reflux, a bitter taste in the mouth, a persistent dry cough, pain when lying down, or regurgitation. While these antacids can cause diarrhea, they do not typically lead to constipation.
Choice C rationale:
Anticholinergics/Antispasmodics Anticholinergics and antispasmodics are used to relieve cramps or spasms of the stomach, intestines, and bladder. Some are used together with antacids or other medicines in the treatment of peptic ulcers. Others are used to prevent nausea, vomiting, and motion sickness. While these medications can cause a variety of side effects, constipation is not a primary side effect.
Choice D rationale:
Opioid narcotics Opioids, also known as narcotics, are a class of drugs healthcare providers prescribe to manage moderate to severe pain, as well as chronic coughing and diarrhea. Common side effects of narcotics include constipation, decreased sweating, dizziness, dry mouth, nose, throat, or skin. Therefore, opioid narcotics are the medication most likely to lead to constipation among the options provided.
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