A client is hyperventilating due to an acute psychologic stressor. The arterial blood gas results show that the client is in respiratory alkalosis. What is the nurse's initial intervention?

Administer an intravenous sedative

Assess the client for seizure activity

Assist the client in slowed breathing techniques

Check the client's blood pressure

Answer and Explanation

The Correct Answer is C

C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.

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Correct Answer is A

Explanation

A. This is crucial because informed consent is not just about signing a document; it's about ensuring that the client fully understands the procedure, including the risks, benefits, and alternatives. The physician can then re-evaluate the client's comprehension and provide further clarification if necessary. It is the responsibility of the healthcare team to ensure that the client is making an informed decision.
B. Explaining the procedure in simple terms may be part of the nurse's role, but it is essential that the physician is aware of any gaps in the client's understanding to address them appropriately.
C. Cancelling the surgery is not the immediate best action without first attempting to resolve the misunderstanding.
D. Witnessing the client's signature may be part of the nurse's role, but it is essential that the physician is aware of any gaps in the client's understanding to address them appropriately.

A. eliminate the hourly assessment of the IV site. B. prevent accidental delivery of large amounts of fluids. C. control the drip rate based on the position of the client. D. administer IV fluids at a rapid rate.

Correct Answer is B

Explanation

B. One of the primary functions of an IV infusion pump is to precisely control the rate and volume of fluid delivery, thereby reducing the risk of accidental administration of large amounts of fluids. The pump allows for accurate programming of infusion rates and volume limits, enhancing safety and preventing fluid overload or other complications.
A. Using an IV infusion pump does not eliminate the need for assessing the IV site regularly. Regardless of the infusion method, it is essential to monitor the IV site frequently for signs of complications such as infiltration, phlebitis, or dislodgement. Therefore, this option is not the appropriate rationale for using an IV infusion pump.

C. IV infusion pumps are programmable devices that allow for precise control of the drip rate independent of the client's position. They ensure a consistent and controlled flow rate regardless of changes in the client's position, providing reliable delivery of fluids or medications.
D. While IV infusion pumps can deliver fluids at various rates, including rapid infusion rates when necessary, their primary purpose is not to administer fluids at a rapid rate. Rather, they are designed to deliver fluids or medications at controlled and programmed rates tailored to the client's needs, ensuring safety and accuracy.

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A client is hyperventilating due to an acute psychologic stressor. The arterial blood gas results show that the client is in respiratory alkalosis. What is the nurse's initial intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician has discussed the need for surgery with a client and has obtained informed consent. The nurse determines that the client does not understand the risks and benefits of the procedure. What is the nurse's best action?

Correct Answer is A

Explanation

The nurse recognizes that the appropriate rationale for using an IV infusion pump for a client is to:

Correct Answer is B

Explanation

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