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 D
Explanation
Choice A rationale:
Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced, often due to hyperventilation. Dry skin is not listed as a common symptom of this condition.
Choice B rationale:
Diarrhea is not a common symptom of respiratory alkalosis. The condition is characterized by symptoms such as dizziness, numbness, confusion, and shortness of breath. Diarrhea is more commonly associated with gastrointestinal issues rather than respiratory conditions.
Choice C rationale:
Abdominal pain is not a typical symptom of respiratory alkalosis. The condition is usually caused by over-breathing
(hyperventilation) that occurs when you breathe very deeply or rapidly. Abdominal pain is not listed as a common symptom of this condition.
Choice D rationale:
Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation, also known as overbreathing, occurs when someone breathes very deeply or rapidly. This can cause the levels of carbon dioxide in the blood to drop too low, leading to respiratory alkalosis. Therefore, a nurse assessing a client who has respiratory alkalosis should expect to find signs of hyperventilation.
Correct Answer is D
Explanation
Choice A rationale:
Numbness in the fingers is not typically a symptom of respiratory acidosis. This condition is characterized by an excess of carbon dioxide (CO2) in the body, which leads to a decrease in the pH of your blood, making it too acidic. Numbness in the fingers could be a symptom of other conditions, such as peripheral neuropathy or Raynaud’s disease.
Choice B rationale:
Abdominal pain is also not a common symptom of respiratory acidosis. While abdominal discomfort can occur in a variety of conditions, it is not directly associated with the acid-base balance disturbance that characterizes respiratory acidosis.
Conditions that commonly cause abdominal pain include gastrointestinal issues like gastritis, appendicitis, or gallstones.
Choice C rationale:
Dry skin is not a symptom of respiratory acidosis. The skin’s condition can be influenced by many factors, including hydration, environmental conditions, and certain skin conditions like eczema or psoriasis. Respiratory acidosis, on the other hand, is a condition that affects the acid-base balance in the body due to alveolar hypoventilation.
Choice D rationale:
Lethargy is indeed a symptom of respiratory acidosis. This condition occurs when the lungs can’t remove enough CO2, leading to an increase in the acidity of the blood. Symptoms of respiratory acidosis vary according to how long you’ve had the condition and its severity. Initial symptoms can include anxiety, blurred vision, and shortness of breath. If left untreated or in severe cases, symptoms may include fatigue, lethargy, delirium, or confusion. Therefore, a nurse assessing a patient with respiratory acidosis should anticipate lethargy among other symptoms.
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