A nurse is assisting with the care of a patient who is receiving supplemental oxygen for hypoxia.
Which of the following findings should the nurse identify as an indication that the intervention was effective?
Respiratory rate 28/min.
Pink mucous membranes.
Heart rate 110/min.
Restlessness.
Restlessness.
The Correct Answer is B
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid. When a person vomits, they lose hydrochloric acid, and the loss of this acid can cause the blood to become more basic. This shift in pH can lead to metabolic alkalosis, a condition characterized by high levels of bicarbonate in the blood, which makes it more alkaline (or less acidic). Symptoms of metabolic alkalosis can include muscle twitching, hand tremor, nausea or vomiting, and tingling in the face, hands or feet. In severe cases, it can cause prolonged muscle contractions or seizures.
Choice B rationale:
Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2) from the body, which causes the body’s fluids, especially the blood, to become too acidic. This can occur due to conditions that affect the lungs such as chronic obstructive pulmonary disease (COPD), asthma, or sleep apnea. However, in the case of a patient experiencing nausea and vomiting, respiratory acidosis is less likely to be the primary concern.
Choice C rationale:
Metabolic acidosis occurs when the body produces too much acid, or when the kidneys aren’t removing enough acid from the body. This can be caused by conditions such as kidney disease, lactic acidosis, or ketoacidosis. In the case of a patient experiencing nausea and vomiting, the primary concern would not typically be metabolic acidosis, as vomiting leads to a loss of stomach acid, which would more likely result in a state of alkalosis, not acidosis.
Choice D rationale:
Respiratory alkalosis is a condition that occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to rise and become too alkaline. When the blood is too alkaline, it means that it is not carrying enough carbon dioxide. This condition can be caused by fever, hyperventilation, or lack of oxygen. In the case of a patient experiencing nausea and vomiting, respiratory alkalosis is not typically the primary concern.
Correct Answer is A
Explanation
Choice A rationale:
Iron supplements Iron supplements are commonly used to treat or prevent iron deficiency anemia. While beneficial in relieving iron deficiency, iron pills can cause side effects like constipation, diarrhea, nausea, vomiting, dark stools, stomach cramps, and a metallic taste. However, constipation is not the primary side effect of iron supplements.
Choice B rationale:
Magnesium-containing antacids Magnesium-containing antacids are used to relieve the symptoms of gastroesophageal reflux disease (GERD), heartburn, or indigestion. By neutralizing stomach acid, antacids relieve symptoms such as burning behind the breast bone or throat area caused by acid reflux, a bitter taste in the mouth, a persistent dry cough, pain when lying down, or regurgitation. While these antacids can cause diarrhea, they do not typically lead to constipation.
Choice C rationale:
Anticholinergics/Antispasmodics Anticholinergics and antispasmodics are used to relieve cramps or spasms of the stomach, intestines, and bladder. Some are used together with antacids or other medicines in the treatment of peptic ulcers. Others are used to prevent nausea, vomiting, and motion sickness. While these medications can cause a variety of side effects, constipation is not a primary side effect.
Choice D rationale:
Opioid narcotics Opioids, also known as narcotics, are a class of drugs healthcare providers prescribe to manage moderate to severe pain, as well as chronic coughing and diarrhea. Common side effects of narcotics include constipation, decreased sweating, dizziness, dry mouth, nose, throat, or skin. Therefore, opioid narcotics are the medication most likely to lead to constipation among the options provided.
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