A client has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas results: pH 7.12, HCO3 22 mEq/L, PaCO2 55 mmHg, PaO2 60 mmHg. Which intervention is the most appropriate?

Apply a paper bag over the clients nose and mouth.

Administer 50 mL of 20% glucose and 20 units of regular insulin.

Administer 50 mL of sodium bicarbonate intravenously.

Apply oxygen by mask or nasal cannula.

Answer and Explanation

The Correct Answer is D

A. Appling a paper bag over the client's nose and mouth is used for hyperventilation or respiratory alkalosis, not for respiratory acidosis. In this case, it would worsen the client’s condition by increasing CO2 retention.

B. Administering 50 mL of 20% glucose and 20 units of regular insulin is appropriate for hyperkalemia or diabetic ketoacidosis, not respiratory acidosis following a seizure.

C. Administering 50 mL of sodium bicarbonate intravenously is used for severe metabolic acidosis. This client’s acidosis is primarily respiratory in origin, making this choice inappropriate.

D. Applying oxygen by mask or nasal cannula helps correct the low oxygen levels and supports respiration post-seizure.

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Correct Answer is C

Explanation

A. Neurologic status is important to monitor but is not directly related to evaluating calcium gluconate's effect on hyperkalemia.

B. Urine volume would not directly reflect the immediate effects of calcium gluconate in managing hyperkalemia.

C. Calcium gluconate is given to protect the heart from the effects of hyperkalemia by stabilizing the cardiac membrane. Monitoring the cardiac rhythm is essential to assess the effectiveness of the treatment.

D. The calcium level is relevant for monitoring the calcium treatment, but cardiac rhythm is a more immediate indicator of its effectiveness.

A. Administer epinephrine 1:1000, 0.3 mg IV push immediately. B. Reassure the client that these symptoms will go away. C. Ensure a patent airway while calling the Rapid Response Team. D. Apply oxygen by facemask at 100% and a pulse oximeter.

Correct Answer is C

Explanation

A. Epinephrine is used in cases of severe allergic reactions or anaphylaxis, and while it may be appropriate in treating angioedema, the first priority is to ensure the airway is clear and that the client can breathe. Administering epinephrine may be part of the treatment plan but should follow securing the airway and calling for immediate advanced help.

B. This is not appropriate because angioedema can be life-threatening and can rapidly progress to airway obstruction. Reassurance without action would delay necessary interventions and could jeopardize the client’s safety.

C. In cases of angioedema, airway obstruction is the most dangerous complication, as it can lead to asphyxiation. The nurse's first priority is to ensure that the patient's airway remains open and clear. The nurse should immediately call the Rapid Response Team (RRT) for urgent medical intervention, which may include medications (like epinephrine), intubation, or other interventions. Ensuring the airway is open and calling for advanced help are the most critical first steps in managing severe cases of angioedema.

D. While oxygen therapy may be appropriate if the client shows signs of respiratory distress or hypoxia, the immediate concern is securing the airway. Oxygen may be needed after ensuring the airway is open, but the priority is to avoid airway obstruction first. The nurse should secure the airway and then administer oxygen if needed.

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A client has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas results: pH 7.12, HCO3 22 mEq/L, PaCO2 55 mmHg, PaO2 60 mmHg. Which intervention is the most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?

Correct Answer is C

Explanation

A client is in the hospital and has received two doses of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below. What action by the nurse is most appropriate?

Correct Answer is C

Explanation

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