NCLEX-RN

Category - Reduction of Risk

A nurse is working in the surgical ward and examining a post-craniotomy client. When monitoring for oxygen toxicity, the nurse should know that this condition could occur when:
  1. Low-flow oxygen is administered for more than 48 hours.
  2. Oxygen concentration is greater than 50%.
  3. Vitamin E and C are deficient.
  4. High oxygen is administered via facial mask.
Explanation
Answer: B - Oxygen toxicity occurs when the oxygen concentration delivered is too high (>50%) and administered for longer than 48 hours. Oxygen toxicity is caused by an accumulation of oxygen free radicals that damage the cells. Clients with Vitamin C and E deficiency are more susceptible to oxygen toxicity, because these clients cannot defend themselves from oxidants. Symptoms of oxygen toxicity include fatigue, dyspnea, paresthesias, respiratory difficulty, and restlessness.
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