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.
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 D
Explanation
Choice A reason: Dry skin is not a sign of respiratory alkalosis. Respiratory alkalosis is a condition where the blood pH is too high due to excessive loss of carbon dioxide through rapid breathing. Dry skin can be caused by dehydration, cold weather, or skin conditions.
Choice B reason: Diarrhea is not a sign of respiratory alkalosis. Diarrhea is a condition where the stool is loose and watery due to increased intestinal motility or infection. Diarrhea can cause metabolic acidosis, which is a condition where the blood pH is too low due to excessive loss of bicarbonate.
Choice C reason: Abdominal pain is not a sign of respiratory alkalosis. Abdominal pain is a symptom that can have many causes, such as gastritis, appendicitis, or irritable bowel syndrome. Abdominal pain can also cause hyperventilation due to anxiety or discomfort, but it is not a direct result of respiratory alkalosis.
Choice D reason: Hyperventilation is a sign of respiratory alkalosis. Hyperventilation is a condition where the breathing rate is faster than normal, causing excess carbon dioxide to be expelled from the lungs. This lowers the partial pressure of carbon dioxide in the blood, which increases the blood pH and causes alkalosis. Hyperventilation can be caused by anxiety, fever, pain, or lung diseases.
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