A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days.
Which of the following findings should the nurse identify as an indication of an adverse effect of oxygen therapy?
Tachycardia
Cracks in oral mucous membranes
Excessive pulmonary secretions
Poor skin turgor
The Correct Answer is B
Choice A rationale:
Tachycardia, or a rapid heart rate, is not typically an adverse effect of oxygen therapy. Oxygen therapy is often used to help people with conditions like COPD, COVID-19, emphysema, and sleep apnea get enough oxygen to function and stay well. While tachycardia can be a symptom of these conditions, it is not directly caused by the oxygen therapy itself.
Choice B rationale:
Cracks in the oral mucous membranes can indeed be an adverse effect of oxygen therapy. Oxygen therapy involves the delivery of highly concentrated oxygen, which can cause irritation and dryness in the airways, including the oral mucous membranes. This can lead to cracks and discomfort in the mouth. Therefore, it’s important for healthcare providers to monitor patients receiving oxygen therapy for signs of this adverse effect.
Excessive pulmonary secretions are not typically a direct adverse effect of oxygen therapy. While conditions that often require oxygen therapy, such as pneumonia and COPD, can lead to increased pulmonary secretions, these are symptoms of the underlying disease rather than the oxygen therapy itself.
Choice D rationale:
Poor skin turgor is not typically an adverse effect of oxygen therapy. Skin turgor refers to the elasticity of the skin, and poor skin turgor is often a sign of dehydration. While oxygen therapy can cause dryness of the mucous membranes, it does not typically affect the hydration status of the skin.
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 B
Explanation
The correct answer is: B. Decreased deep tendon reflexes.
Choice A rationale: Wheezing is not typically associated with hyperkalemia. It is more commonly related to respiratory conditions.
Choice B rationale: Hyperkalemia can cause decreased deep tendon reflexes due to the effect of high potassium levels on nerve conduction and muscle function.
Choice C rationale: Hypoactive bowel sounds are not a common sign of hyperkalemia. They are more often associated with gastrointestinal issues.
Choice D rationale: Cerebral edema is not related to hyperkalemia. It is usually associated with conditions affecting the brain, such as trauma or infections.
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