A nurse is assessing a client who has respiratory alkalosis.
Which of the following findings should the nurse expect?
Dry skin
Diarrhea
Abdominal pain
Hyperventilation
Hyperventilation
The Correct Answer is D
Choice A rationale:
Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced, often due to hyperventilation. Dry skin is not listed as a common symptom of this condition.
Choice B rationale:
Diarrhea is not a common symptom of respiratory alkalosis. The condition is characterized by symptoms such as dizziness, numbness, confusion, and shortness of breath. Diarrhea is more commonly associated with gastrointestinal issues rather than respiratory conditions.
Choice C rationale:
Abdominal pain is not a typical symptom of respiratory alkalosis. The condition is usually caused by over-breathing
(hyperventilation) that occurs when you breathe very deeply or rapidly. Abdominal pain is not listed as a common symptom of this condition.
Choice D rationale:
Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation, also known as overbreathing, occurs when someone breathes very deeply or rapidly. This can cause the levels of carbon dioxide in the blood to drop too low, leading to respiratory alkalosis. Therefore, a nurse assessing a client who has respiratory alkalosis should expect to find signs of hyperventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid. When a person vomits, they lose hydrochloric acid, and the loss of this acid can cause the blood to become more basic. This shift in pH can lead to metabolic alkalosis, a condition characterized by high levels of bicarbonate in the blood, which makes it more alkaline (or less acidic). Symptoms of metabolic alkalosis can include muscle twitching, hand tremor, nausea or vomiting, and tingling in the face, hands or feet. In severe cases, it can cause prolonged muscle contractions or seizures.
Choice B rationale:
Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2) from the body, which causes the body’s fluids, especially the blood, to become too acidic. This can occur due to conditions that affect the lungs such as chronic obstructive pulmonary disease (COPD), asthma, or sleep apnea. However, in the case of a patient experiencing nausea and vomiting, respiratory acidosis is less likely to be the primary concern.
Choice C rationale:
Metabolic acidosis occurs when the body produces too much acid, or when the kidneys aren’t removing enough acid from the body. This can be caused by conditions such as kidney disease, lactic acidosis, or ketoacidosis. In the case of a patient experiencing nausea and vomiting, the primary concern would not typically be metabolic acidosis, as vomiting leads to a loss of stomach acid, which would more likely result in a state of alkalosis, not acidosis.
Choice D rationale:
Respiratory alkalosis is a condition that occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to rise and become too alkaline. When the blood is too alkaline, it means that it is not carrying enough carbon dioxide. This condition can be caused by fever, hyperventilation, or lack of oxygen. In the case of a patient experiencing nausea and vomiting, respiratory alkalosis is not typically the primary concern.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.
Choice B rationale:
The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.
Choice C rationale:
The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.
Choice D rationale:
The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.
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