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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Collecting urine from the catheter’s port is not the correct procedure when collecting a urine specimen for culture and sensitivity through straight catheterization. The port is not a sterile environment and could contaminate the specimen, leading to inaccurate results.
Choice B rationale:
Using a sterile specimen container is the correct procedure. This ensures that the specimen is not contaminated by any external bacteria or substances, which could affect the results of the culture and sensitivity test. The container must be sterile to prevent the growth of microbes that are not present in the urine sample. This helps to ensure that the results of the culture are accurate and reflect the microbes present in the urine, not those introduced during collection.
Choice C rationale:
Inflating the balloon with sterile water is not a step in this procedure. The balloon is part of an indwelling catheter, not a straight catheter. An indwelling catheter remains in the bladder for a longer period, and the balloon is inflated to keep it in place. A straight catheter is used for a single voiding or to obtain a sterile urine specimen.
Choice D rationale:
Instructing the patient to clean from front to back with an antiseptic solution is not a step in this procedure. While maintaining cleanliness is important, this specific instruction is more relevant to a clean-catch midstream urine specimen, not a specimen collected through straight catheterization.
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
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