Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?
A. Metallic taste in mouth
Metallic taste in the mouth:This is not a typical finding of oxygen toxicity. Metallic taste may be associated with other factors but is not a specific indicator of oxygen toxicity.
B. Facial flushing
Facial flushing:Facial flushing is not a typical finding in oxygen toxicity. It is more commonly associated with other conditions, such as certain allergic reactions or vasodilation.
C. Muscle twitching
Muscle twitching, also known as myoclonus, is a recognized symptom of central nervous system oxygen toxicity. High concentrations of oxygen, particularly at increased pressures, can cause neurotoxic effects leading to muscle twitching, dizziness, and even convulsions.
D. Periorbital edema
Periorbital edema:Periorbital edema is not a common manifestation of oxygen toxicity. It is more commonly associated with conditions related to fluid balance or kidney function.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nrsg 200 Proctored Exam 1 2023 With Ngn A. Take the full exam now
Full Explanation
A. Metallic taste in the mouth:
This is not a typical finding of oxygen toxicity. Metallic taste may be associated with other factors but is not a specific indicator of oxygen toxicity.
B. Facial flushing:
Facial flushing is not a typical finding in oxygen toxicity. It is more commonly associated with other conditions, such as certain allergic reactions or vasodilation.
C. Muscle twitching
Muscle twitching, also known as myoclonus, is a recognized symptom of central nervous system oxygen toxicity. High concentrations of oxygen, particularly at increased pressures, can cause neurotoxic effects leading to muscle twitching, dizziness, and even convulsions.
D. Periorbital edema:
Periorbital edema is not a common manifestation of oxygen toxicity. It is more commonly associated with conditions related to fluid balance or kidney function.
Similar Questions
A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?
A. Instructions on how to change ventilator settings
Instructions on how to change ventilator settings:Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.
B. Instructions on mouth care
Instructions on mouth careMouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.
C. Instructions to suction the client’s tracheostomy every 2 hr
Instructions to suction the client’s tracheostomy every 2 hr: Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.
D. Instructions to place the client in a supine position
Instructions to place the client in a supine position:The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.
Full Explanation
A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.
B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.
C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.
D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.
A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client’s care?
A. integrity of the dressing
Integrity of the dressing:Dressing integrity is important for wound care, but it is not the top priority when considering the client's immediate postoperative needs.
B. Need for suctioning
Need for suctioningMaintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx removes the client's ability to breathe through the nose and mouth, so maintaining a clear airway is a top priority. Suctioning may be necessary to remove secretions and maintain airway patency.
C. Patency of the intravenous line
Patency of the intravenous line: Intravenous line patency is important for fluid and medication administration, but it is not the priority when compared to maintaining a clear airway.
D. Level of pain
Level of pain:Pain management is important for the client's comfort, but it is not the immediate priority compared to ensuring a patent airway following a total laryngectomy.
Full Explanation
A. Integrity of the dressing:
Dressing integrity is important for wound care, but it is not the top priority when considering the client's immediate postoperative needs.
B. Need for suctioning
Maintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx removes the client's ability to breathe through the nose and mouth, so maintaining a clear airway is a top priority. Suctioning may be necessary to remove secretions and maintain airway patency.
C. Patency of the intravenous line:
Intravenous line patency is important for fluid and medication administration, but it is not the priority when compared to maintaining a clear airway.
D. Level of pain:
Pain management is important for the client's comfort, but it is not the immediate priority compared to ensuring a patent airway following a total laryngectomy.
A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of the nurses clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?
A. Cooperating
Cooperating involves working together to find a mutually beneficial solution. In this case, the charge nurse resolves the conflict by allowing both nurses to go to lunch together and taking care of their clients, ensuring that both nurses’ needs are met.
B. Avoiding
Avoiding means ignoring the conflict or withdrawing from the situation. The charge nurse is not ignoring the conflict; rather, they are actively facilitating a resolution by allowing both nurses to take lunch together.
C. Compromising
Compromising involves both parties giving up something to reach a mutually acceptable solution. While the charge nurse is helping to resolve the conflict by allowing the nurses to go to lunch, it does not imply that either nurse has made a concession in their argument, making this option less accurate.
D. Competing
Competing:Competing involves pursuing one's own concerns at the expense of others. It is a win-lose approach to conflict resolution. The charge nurse is not demonstrating a competitive approach in this scenario, as both nurses are accommodated to go to lunch together without one person's needs being prioritized over the other.
Full Explanation
A. Cooperating:Cooperating involves working together to find a mutually beneficial solution. In this case, the charge nurse resolves the conflict by allowing both nurses to go to lunch together and taking care of their clients, ensuring that both nurses’ needs are met.
B. Avoiding:Avoiding means ignoring the conflict or withdrawing from the situation. The charge nurse is not ignoring the conflict; rather, they are actively facilitating a resolution by allowing both nurses to take lunch together.
C. Compromising:Compromising involves both parties giving up something to reach a mutually acceptable solution. While the charge nurse is helping to resolve the conflict by allowing the nurses to go to lunch, it does not imply that either nurse has made a concession in their argument, making this option less accurate.
D. Competing:
Competing involves pursuing one's own concerns at the expense of others. It is a win-lose approach to conflict resolution. The charge nurse is not demonstrating a competitive approach in this scenario, as both nurses are accommodated to go to lunch together without one person's needs being prioritized over the other.