A nurse is caring for a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen therapy at home. The nurse should instruct the client to report which of the following findings as an indication of oxygen toxicity?
Headache
Dry mouth
Increased appetite
Nausea
The Correct Answer is A
Choice A reason: Headache is a sign of oxygen toxicity, which is a condition that occurs when the client receives too much oxygen for a prolonged period of time. Oxygen toxicity can damage the lungs and other organs, and cause symptoms such as confusion, seizures, and respiratory failure. The nurse should instruct the client to report headache and adjust the oxygen flow rate accordingly.
Choice B reason: Dry mouth is not a sign of oxygen toxicity, but it could be a side effect of some medications or a result of dehydration. The nurse should instruct the client to drink plenty of fluids and use a humidifier or a nasal saline spray to moisten the mucous membranes.
Choice C reason: Increased appetite is not a sign of oxygen toxicity, but it could be a positive outcome of oxygen therapy, as it indicates improved oxygenation and metabolism. The nurse should encourage the client to eat a balanced diet and monitor their weight and nutritional status.
Choice D reason: Nausea is not a sign of oxygen toxicity, but it could be a side effect of some medications or a symptom of another condition, such as gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD). The nurse should instruct the client to take their medications as prescribed and avoid foods that trigger nausea, such as spicy, fatty, or acidic foods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a statement that indicates a need for further teaching. The client is doing wheelchair exercises while watching TV, which is a good way to maintain physical activity and prevent muscle atrophy and contractures. The nurse should praise the client for this behavior and encourage them to continue.
Choice B reason: This is not a statement that indicates a need for further teaching. The client is carrying a water bottle with them and drinking a lot of water, which is a good way to prevent dehydration and urinary tract infections. The nurse should praise the client for this behavior and remind them to drink at least 2 liters of water per day.
Choice C reason: This is not a statement that indicates a need for further teaching. The client is using a suppository every night to have a bowel movement, which is a common method of managing bowel dysfunction in clients with spina bifida. The nurse should ask the client about their bowel routine and provide any additional education or support as needed.
Choice D reason: This is a statement that indicates a need for further teaching. The client is only catheterizing themselves twice every day, which is not enough to prevent urinary retention and infection. The nurse should explain to the client that they need to catheterize themselves at least every 4 to 6 hours, or as prescribed by the provider. The nurse should also demonstrate the proper technique and hygiene for catheterization and assess the client's ability to perform it.
Correct Answer is ["A","B","D"]
Explanation
Choice A: The reason why the child is taking the medication
It is essential for the nurse to explain why the child is taking the medication. This helps the parents or caregivers understand the importance of the medication and ensures they are more likely to adhere to the prescribed treatment plan. Knowing the reason for the medication can also help in recognizing the signs of improvement or any potential issues that may arise during the course of treatment.
Choice B: The adverse effects of the medication
Informing the parents or caregivers about the potential adverse effects of the medication is crucial. This knowledge allows them to monitor the child for any side effects and seek medical attention if necessary. It also helps in managing expectations and reduces anxiety if any common side effects occur.
Choice C: Stopping the medication when the child feels better
This is not a correct choice. It is important to complete the full course of antibiotics as prescribed, even if the child starts feeling better. Stopping the medication prematurely can lead to incomplete treatment of the infection and may contribute to antibiotic resistance.
Choice D: Written information about the medication
Providing written information about the medication is important as it serves as a reference for the parents or caregivers. This information can include dosage instructions, potential side effects, and any other relevant details. Written instructions help ensure that the medication is administered correctly and consistently.
Choice E: Using a kitchen spoon to administer the medication
This is not a correct choice. Using a kitchen spoon to administer medication is not recommended as it can lead to inaccurate dosing. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage is given.
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