A nurse is caring for a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen therapy at home. The nurse should instruct the client to report which of the following findings as an indication of oxygen toxicity?
Headache
Dry mouth
Increased appetite
Nausea
The Correct Answer is A
Choice A reason: Headache is a sign of oxygen toxicity, which is a condition that occurs when the client receives too much oxygen for a prolonged period of time. Oxygen toxicity can damage the lungs and other organs, and cause symptoms such as confusion, seizures, and respiratory failure. The nurse should instruct the client to report headache and adjust the oxygen flow rate accordingly.
Choice B reason: Dry mouth is not a sign of oxygen toxicity, but it could be a side effect of some medications or a result of dehydration. The nurse should instruct the client to drink plenty of fluids and use a humidifier or a nasal saline spray to moisten the mucous membranes.
Choice C reason: Increased appetite is not a sign of oxygen toxicity, but it could be a positive outcome of oxygen therapy, as it indicates improved oxygenation and metabolism. The nurse should encourage the client to eat a balanced diet and monitor their weight and nutritional status.
Choice D reason: Nausea is not a sign of oxygen toxicity, but it could be a side effect of some medications or a symptom of another condition, such as gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD). The nurse should instruct the client to take their medications as prescribed and avoid foods that trigger nausea, such as spicy, fatty, or acidic foods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.
Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.
Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.
Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.
Correct Answer is C
Explanation
Choice A reason: Improved hydration is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Hydration status should be monitored for any child with a respiratory infection, but it does not reflect the severity of the airway inflammation.
Choice B reason: Decreased temperature is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Fever may or may not be present in this condition, and it does not correlate with the degree of airway obstruction.
Choice C reason: Decreased stridor is a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Stridor is a high-pitched sound caused by turbulent airflow through a narrowed upper airway. It indicates a significant obstruction that can compromise breathing. A reduction in stridor means that the airway inflammation has subsided and the child can breathe more easily.
Choice D reason: Barking cough is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Barking cough is a characteristic symptom of this condition, caused by the swelling of the vocal cords. It may persist for several days after the acute episode, even when the child is improving.
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