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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. When a client experiences symptoms of extravasation, such as pain, burning, and swelling, especially with a vesicant medication, the priority is to stop the infusion and remove the catheter immediately to prevent further tissue damage. Removing the catheter promptly helps minimize the amount of medication that may have leaked into the surrounding tissues.
A. Elevating the extremity on a pillow may help reduce swelling and discomfort in some cases, but it is not the first action the nurse should take when a vesicant medication has caused pain, burning, and swelling at the IV site.
C. Keeping the catheter in place is not advisable when extravasation has occurred, especially with a vesicant medication. Continuing the infusion could lead to further tissue damage and exacerbate the client's symptoms. Removing the catheter is necessary to prevent additional medication from entering the surrounding tissues.
D. While applying a cool compress may provide temporary relief from discomfort, it is not the first action the nurse should take when managing extravasation caused by a vesicant medication. The priority is to stop the infusion, remove the catheter, and assess the extent of tissue damage. Cool compresses may be used after the catheter removal to help reduce swelling and discomfort.
Correct Answer is C
Explanation
C. Prioritizing essential information and presenting it first can increase the likelihood that the client grasps key concepts and retains important details. By focusing on the most crucial information initially, the client is more likely to understand and remember the core concepts of the teaching session. This approach helps prevent information overload and ensures that the client receives the most critical information upfront, enhancing their learning outcomes.
A. Extreme temperatures, whether too hot or too cold, can be distracting and uncomfortable for the client, potentially detracting from their ability to focus on the teaching session and retain information.
B. Postponing a teaching session if the client appears to be mildly anxious: This strategy acknowledges the importance of addressing the client's emotional state in facilitating effective learning. If a client appears to be mildly anxious or emotionally distressed, it may be beneficial to postpone the teaching session temporarily until the client feels more calm and receptive to learning. Addressing the client's emotional needs and ensuring a supportive environment can enhance their ability to engage in the teaching process and retain information effectively.
D. While some individuals may find listening to music relaxing or enjoyable, it can also serve as a distraction during a teaching session, especially if the music competes with the nurse's instructions or interferes with the client's ability to concentrate.
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