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
Choice A rationale:
Taking the patient to the bathroom every 2 hours while the patient is awake is not the most effective strategy for a bowel training program. This approach does not take into account the natural rhythms of the body and the patient’s personal comfort. It may lead to unnecessary trips to the bathroom, which can be physically and emotionally draining for the patient.
Choice B rationale:
This is the correct answer. A bowel training program aims to help the patient regain control over their bowel movements. Taking the patient to the bathroom when they have the urge to defecate aligns with this goal. It allows the patient to respond to their body’s signals, which can help improve their confidence and independence over time.
Choice C rationale:
Taking the patient to the bathroom immediately before meals is not the most effective strategy for a bowel training program. While it’s true that eating can stimulate bowel movements due to the gastrocolic reflex, this approach does not consider the patient’s comfort or individual needs. It may also disrupt the patient’s enjoyment of their meals.
Choice D rationale:
Waiting until the patient feels abdominal cramping is not the most effective strategy for a bowel training program. Abdominal cramping can be a sign of constipation or other digestive issues. It’s important to address these issues separately and not rely on them as indicators for when to take the patient to the bathroom.
Correct Answer is D
Explanation
Choice A rationale:
The stool guaiac test does not check for bacteria in the feces. This test is used to detect hidden (occult) blood in a stool sample. It is the most common type of fecal occult blood test (FOBT)1.
Choice B rationale:
The stool guaiac test does not check for fat in the feces. The presence of fat in the feces is usually checked by a different test called a fecal fat test. The stool guaiac test is specifically designed to detect the presence of hidden blood in the stool.
Choice C rationale:
The stool guaiac test does not check for parasites in the feces. Parasites are typically detected using a stool ova and parasites (O&P) test. The stool guaiac test is used to detect hidden blood in the stool, which could be an indication of various conditions, including colon cancer or polyps in the colon or rectum.
Choice D rationale:
The stool guaiac test checks for hidden blood in the feces. This is the correct answer. The test can find blood even if you cannot see it yourself. Occult blood in the stool may indicate colon cancer or polyps in the colon or rectum, though not all cancers or polyps bleed. If blood is detected through a fecal occult blood test, additional tests may be needed to determine the source of the bleeding. The stool guaiac test can only detect the presence or absence of blood — it can’t determine what’s causing the bleeding.
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