A nurse is assisting with the care of a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?
Respiratory rate 28/min
Pink mucous membranes
Heart rate 110/min
Restlessness
The Correct Answer is B
Choice A reason: Respiratory rate 28/min is not a sign of effective oxygen therapy, as it indicates tachypnea, which is a rapid breathing rate. Tachypnea can be caused by hypoxia, anxiety, fever, or pain.
Choice B reason: Pink mucous membranes are a sign of effective oxygen therapy, as they indicate adequate oxygenation of the tissues. Pink mucous membranes are a normal finding, while pale, cyanotic, or jaundiced mucous membranes can indicate hypoxia or other problems.
Choice C reason: Heart rate 110/min is not a sign of effective oxygen therapy, as it indicates tachycardia, which is a rapid heart rate. Tachycardia can be caused by hypoxia, stress, dehydration, or infection.
Choice D reason: Restlessness is not a sign of effective oxygen therapy, as it indicates agitation, anxiety, or discomfort. Restlessness can be caused by hypoxia, pain, or medication side effects.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason: Tachycardia is not an adverse effect of oxygen therapy. Tachycardia is a condition where the heart rate is faster than normal, usually above 100 beats per minute. Tachycardia can be caused by various factors, such as fever, infection, pain, or anxiety. Tachycardia can also be a sign of hypoxemia, which is a low level of oxygen in the blood, and may indicate the need for oxygen therapy.
Choice B reason: Cracks in oral mucous membranes are an adverse effect of oxygen therapy. Cracks in oral mucous membranes are a sign of dryness and irritation caused by the oxygen flow. Oxygen therapy can reduce the natural moisture and lubrication of the mouth and nose, leading to discomfort and increased risk of infection. To prevent or treat this problem, the nurse should provide the client with humidified oxygen, oral care, and hydration.
Choice C reason: Excessive pulmonary secretions are not an adverse effect of oxygen therapy. Excessive pulmonary secretions are a sign of inflammation and infection in the lungs, which can impair gas exchange and cause coughing, wheezing, and dyspnea. Excessive pulmonary secretions can be a symptom of pneumonia, which is a common cause of respiratory failure and may require oxygen therapy.
Choice D reason: Poor skin turgor is not an adverse effect of oxygen therapy. Poor skin turgor is a sign of dehydration, which is a loss of fluid from the body. Dehydration can be caused by various factors, such as vomiting, diarrhea, fever, or inadequate intake. Dehydration can affect the blood volume and pressure, and may worsen the oxygen delivery to the tissues. To prevent or treat this problem, the nurse should monitor the client's fluid balance and provide adequate hydration.
Correct Answer is B
Explanation
The correct answer is b. Decreased deep tendon reflexes.
Choice A: Wheezing
Reason: Wheezing is typically associated with respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or allergic reactions. It is not a common manifestation of hyperkalemia. Hyperkalemia primarily affects the muscular and cardiovascular systems rather than the respiratory system.
Choice B: Decreased deep tendon reflexes
Reason: Hyperkalemia can cause neuromuscular symptoms, including muscle weakness and decreased deep tendon reflexes. High potassium levels interfere with the normal function of muscle cells and nerves, leading to these symptoms. This is a direct result of the altered action potentials in neurons caused by elevated potassium levels.
Choice C: Hypoactive bowel sounds
Reason: Hypoactive bowel sounds are generally associated with conditions that cause decreased gastrointestinal motility, such as ileus or bowel obstruction. While hyperkalemia can affect muscle function, it is more likely to cause hyperactive bowel sounds due to increased gastrointestinal motility rather than hypoactive sounds.
Choice D: Cerebral edema
Reason: Cerebral edema is swelling of the brain and is not a typical manifestation of hyperkalemia. It is more commonly associated with conditions such as traumatic brain injury, stroke, or severe infections. Hyperkalemia primarily affects the heart and muscles.
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