A nurse is collecting data on a client who has oxygen toxicity. Which of the following findings should the nurse expect?
Muscle twitching
Facial flushing
Periorbital edema
Metallic taste in mouth
The Correct Answer is A
Choice A reason: Muscle twitching is a sign of central nervous system oxygen toxicity, which can occur when breathing high concentrations of oxygen under pressure. It can also cause seizures, confusion, and loss of consciousness.
Choice B reason: Facial flushing is not a symptom of oxygen toxicity. It can be caused by other conditions such as fever, allergic reactions, or alcohol consumption.
Choice C reason: Periorbital edema is not a symptom of oxygen toxicity. It can be caused by other conditions such as kidney disease, heart failure, or allergies.
Choice D reason: Metallic taste in mouth is not a symptom of oxygen toxicity. It can be caused by other conditions such as medication side effects, dental problems, or infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Muscle weakness.
Choice A: Hypertension
Reason: Hypertension, or high blood pressure, is not a typical manifestation of hypokalemia. Hypokalemia primarily affects muscle function and the nervous system. While potassium imbalances can influence blood pressure, hypertension is more commonly associated with hyperkalemia (high potassium levels) rather than hypokalemia.
Choice B: Cerebral Edema
Reason: Cerebral edema, which is swelling of the brain, is not a known manifestation of hypokalemia. Hypokalemia affects muscle and nerve function, but it does not directly cause cerebral edema. This condition is more related to severe head injuries, infections, or other medical conditions.
Choice C: Muscle Weakness
Reason: Muscle weakness is a common and significant manifestation of hypokalemia. Potassium is crucial for muscle function, and low levels can lead to muscle weakness, cramps, and even paralysis in severe cases. This is because potassium helps in the transmission of nerve signals to muscles, and a deficiency disrupts this process.
Choice D: Hyperactive Bowel Sounds
Reason: Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, hypokalemia can lead to decreased bowel motility, resulting in symptoms like constipation or ileus (a condition where the intestines do not move properly). This is due to the role of potassium in muscle contractions, including those in the digestive tract.
Correct Answer is C
Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
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