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 correct instruction for the nurse to include in the teaching plan. The parents should not remove the harness when bathing the infant, as this may interrupt the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness, and to keep the harness clean and dry.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not adjust the straps of the Pavlik harness by themselves, as this may affect the position and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.
Choice C reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not place a thin layer of clothing under the straps of the harness, as this may interfere with the proper alignment and function of the harness. The nurse should instruct the parents to dress the infant in loose-fitting clothing over the harness, and to avoid using bulky or cloth diapers.
Choice D reason: This is a correct instruction for the nurse to include in the teaching plan. The parents should check the infant's skin under the straps of the harness for redness or irritation, as this may indicate skin breakdown or infection. The nurse should instruct the parents to keep the infant's skin clean and dry, and to report any signs of redness, swelling, or drainage.
Correct Answer is B
Explanation
Choice A reason: Glyburide is an oral medication that lowers blood sugar by stimulating the pancreas to produce more insulin. It is not used for type 1 diabetes mellitus, as the pancreas cannot produce enough insulin in this condition. Glyburide is used for type 2 diabetes mellitus, which is caused by insulin resistance.
Choice B reason: Obtaining an influenza vaccine annually is recommended for people who have type 1 diabetes mellitus, as they are more prone to complications from the flu, such as pneumonia, ketoacidosis, and hospitalization. The vaccine can help prevent or reduce the severity of the flu and its complications.
Choice C reason: Injecting insulin in the deltoid muscle is not the best practice for administering insulin, as the absorption rate and onset of action may vary depending on the muscle mass and blood flow. The preferred sites for insulin injection are the abdomen, the upper arms, the thighs, and the buttocks, as they have more subcutaneous fat and less muscle tissue. The injection site should also be rotated to prevent lipodystrophy.
Choice D reason: Administering glucagon for hyperglycemia is not appropriate, as glucagon is a hormone that raises blood sugar by stimulating the liver to release glucose. It is used for hypoglycemia, or low blood sugar, which is a common and serious complication of type 1 diabetes mellitus. Hyperglycemia, or high blood sugar, is treated with insulin, fluids, and electrolytes.
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