The client is started on 90% oxygen by nonrebreather mask at 0800. The nurse working the night shift assesses the client, who complains of substernal pain and dyspnea and has rales audible in the lower lung field bilaterally
Based on these assessment findings, what does the nurse suspect?
1. Myocardial hypoxia
2. Pulmonary emboli
3. Oxygen toxicity
4. Congestive heart failure
Correct Answer: 3
Oxygen toxicity can develop as early as 12 hours after breathing high concentrations of oxygen, and is indicated by substernal pain, cough, sore throat, dyspnea, and pulmonary edema. Oxygen toxicity should be ruled out before assessing for other causes.
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