Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data on a client who has oxygen toxicity. Which of the following findings should the nurse expect?
A. Muscle twitching
Muscle twitching is a sign of central nervous system oxygen toxicity, which can occur when breathing high concentrations of oxygen under pressure. It can also cause seizures, confusion, and loss of consciousness.
B. Facial flushing
Facial flushing is not a symptom of oxygen toxicity. It can be caused by other conditions such as fever, allergic reactions, or alcohol consumption.
C. Periorbital edema
Periorbital edema is not a symptom of oxygen toxicity. It can be caused by other conditions such as kidney disease, heart failure, or allergies.
D. Metallic taste in mouth
Metallic taste in mouth is not a symptom of oxygen toxicity. It can be caused by other conditions such as medication side effects, dental problems, or infections.
This question is an excerpt from Nurse Dive's nursing test bank - NS117 T Winter 2023 Monroe college NY PN Fundamental of nursing proctored exam 2. Take the full exam now
Full Explanation
Choice A reason: Muscle twitching is a sign of central nervous system oxygen toxicity, which can occur when breathing high concentrations of oxygen under pressure. It can also cause seizures, confusion, and loss of consciousness.
Choice B reason: Facial flushing is not a symptom of oxygen toxicity. It can be caused by other conditions such as fever, allergic reactions, or alcohol consumption.
Choice C reason: Periorbital edema is not a symptom of oxygen toxicity. It can be caused by other conditions such as kidney disease, heart failure, or allergies.
Choice D reason: Metallic taste in mouth is not a symptom of oxygen toxicity. It can be caused by other conditions such as medication side effects, dental problems, or infections.
Similar Questions
A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
A. Confirm the client's identity by checking their wristband.
B. Provide for the client's privacy by closing the curtains.
C. Assist the client into the Sims' position.
D. Insert the tip of the enema tubing into the client's rectum.
Full Explanation
Choice A reason: Confirming the client's identity by checking their wristband is the first step to ensure that the right client receives the right treatment.
Choice B reason: Providing for the client's privacy by closing the curtains is the second step to respect the client's dignity and comfort.
Choice C reason: Assisting the client into the Sims' position is the third step to facilitate the insertion of the enema tubing and the flow of the solution. The Sims' position is a side-lying position with the upper leg flexed and the lower leg straight.
Choice D reason: Inserting the tip of the enema tubing into the client's rectum is the fourth and final step to administer the enema. The nurse should lubricate the tip of the tubing, gently insert it about 3 to 4 inches into the rectum, and release the clamp to allow the solution to flow. The nurse should monitor the client for any signs of discomfort or cramping and adjust the flow rate accordingly.
A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching?
A. I do my wheelchair exercises sitting in my chair.
Doing wheelchair exercises sitting in the chair is a correct statement, as it helps to prevent pressure ulcers, improve circulation, and maintain muscle tone.
B. I use a suppository every night to have a bowel movement.
Using a suppository every night to have a bowel movement is an incorrect statement, as it indicates a dependence on laxatives and a lack of bowel training. The adolescent should be taught to establish a regular bowel routine, use natural methods such as abdominal massage and digital stimulation, and avoid overuse of laxatives.
C. I need to catheterize myself twice a day.
Needing to catheterize oneself twice a day is a correct statement, as it helps to prevent urinary tract infections, bladder distension, and kidney damage.
D. I carry a water bottle with me because I drink a lot of water.
Carrying a water bottle with me because I drink a lot of water is a correct statement, as it helps to prevent dehydration, constipation, and urinary tract infections.
Full Explanation
Choice A reason: Doing wheelchair exercises sitting in the chair is a correct statement, as it helps to prevent pressure ulcers, improve circulation, and maintain muscle tone.
Choice B reason: Using a suppository every night to have a bowel movement is an incorrect statement, as it indicates a dependence on laxatives and a lack of bowel training. The adolescent should be taught to establish a regular bowel routine, use natural methods such as abdominal massage and digital stimulation, and avoid overuse of laxatives.
Choice C reason: Needing to catheterize oneself twice a day is a correct statement, as it helps to prevent urinary tract infections, bladder distension, and kidney damage.
Choice D reason: Carrying a water bottle with me because I drink a lot of water is a correct statement, as it helps to prevent dehydration, constipation, and urinary tract infections.
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
A. Request that the provider prescribe a stool softener.
Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
B. Add fluid and fiber to the diet.
Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
C. Promote active range-of-motion activities.
Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
D. Avoid gas-producing foods.
Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
Full Explanation
Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.