A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days.
Which of the following findings should the nurse identify as an indication of an adverse effect of oxygen therapy?
Tachycardia
Cracks in oral mucous membranes
Excessive pulmonary secretions
Poor skin turgor
The Correct Answer is B
Choice A rationale:
Tachycardia, or a rapid heart rate, is not typically an adverse effect of oxygen therapy. Oxygen therapy is often used to help people with conditions like COPD, COVID-19, emphysema, and sleep apnea get enough oxygen to function and stay well. While tachycardia can be a symptom of these conditions, it is not directly caused by the oxygen therapy itself.
Choice B rationale:
Cracks in the oral mucous membranes can indeed be an adverse effect of oxygen therapy. Oxygen therapy involves the delivery of highly concentrated oxygen, which can cause irritation and dryness in the airways, including the oral mucous membranes. This can lead to cracks and discomfort in the mouth. Therefore, it’s important for healthcare providers to monitor patients receiving oxygen therapy for signs of this adverse effect.
Excessive pulmonary secretions are not typically a direct adverse effect of oxygen therapy. While conditions that often require oxygen therapy, such as pneumonia and COPD, can lead to increased pulmonary secretions, these are symptoms of the underlying disease rather than the oxygen therapy itself.
Choice D rationale:
Poor skin turgor is not typically an adverse effect of oxygen therapy. Skin turgor refers to the elasticity of the skin, and poor skin turgor is often a sign of dehydration. While oxygen therapy can cause dryness of the mucous membranes, it does not typically affect the hydration status of the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: B. Decreased deep tendon reflexes.
Choice A rationale: Wheezing is not typically associated with hyperkalemia. It is more commonly related to respiratory conditions.
Choice B rationale: Hyperkalemia can cause decreased deep tendon reflexes due to the effect of high potassium levels on nerve conduction and muscle function.
Choice C rationale: Hypoactive bowel sounds are not a common sign of hyperkalemia. They are more often associated with gastrointestinal issues.
Choice D rationale: Cerebral edema is not related to hyperkalemia. It is usually associated with conditions affecting the brain, such as trauma or infections.
Correct Answer is A
Explanation
Choice A rationale:
Urinary retention is a condition where the bladder doesn’t empty all the way or at all when you urinate. This can lead to leakage of urine, as the bladder is overfilled and may result in small amounts of urine escaping. This symptom is often associated with urinary retention and is therefore a likely finding in a client with this condition.
Choice B rationale:
Dark-colored urine is not typically a direct symptom of urinary retention. It can be a sign of dehydration, certain dietary factors, or a side effect of some medications. While it’s possible for a person with urinary retention to have dark-colored urine, it’s not a specific or direct symptom of the condition.
Cloudy urine can be a sign of a urinary tract infection (UTI), which can occur as a complication of urinary retention. However, it’s not a direct symptom of urinary retention itself. A nurse would not necessarily expect to see cloudy urine in a client with urinary retention unless a UTI or another complication was present.
Choice D rationale:
Blood in the urine, or hematuria, is not a typical symptom of urinary retention. It can be a sign of various conditions, including UTIs, kidney stones, or more serious conditions like bladder or kidney disease. While it’s possible for a person with urinary retention to have blood in their urine, it’s not a direct symptom of the condition.
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