A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating.
What action should the nurse take?
Plan to administer insulin to the client.
Have the client breathe into a paper bag.
Plan to administer sodium bicarbonate to the client.
Have the client place their head between their knees.
The Correct Answer is B
Choice A rationale:
Administering insulin to a client who is hyperventilating due to respiratory alkalosis would not be the appropriate action. Insulin is used to lower blood glucose levels in clients with hyperglycemia, such as those with diabetes mellitus. It does not directly address the issues of hyperventilation or respiratory alkalosis.
Choice B rationale:
Having the client breathe into a paper bag is the correct action in this case. When a person hyperventilates, they exhale more carbon dioxide (CO2) than they produce. This can lead to a state of respiratory alkalosis, where the blood becomes too alkaline due to the low levels of CO2. By breathing into a paper bag, the client re-inhales some of the exhaled CO2, helping to restore the balance of gases in the blood and alleviate the symptoms of respiratory alkalosis.
Choice C rationale:
Administering sodium bicarbonate to a client who is hyperventilating and has respiratory alkalosis would not be the appropriate action. Sodium bicarbonate is an alkalinizing agent used to treat conditions where there is too much acid in the body, such as metabolic acidosis. In this case, the client’s body is too alkaline due to the respiratory alkalosis, so administering an alkalinizing agent would exacerbate the condition.
Choice D rationale:
Having the client place their head between their knees would not be the appropriate action for a client who is hyperventilating due to respiratory alkalosis. This position is often used to help alleviate symptoms of dizziness or fainting, but it does not address the underlying issue of the imbalance of gases in the blood due to hyperventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Taking the patient to the bathroom every 2 hours while the patient is awake is not the most effective strategy for a bowel training program. This approach does not take into account the natural rhythms of the body and the patient’s personal comfort. It may lead to unnecessary trips to the bathroom, which can be physically and emotionally draining for the patient.
Choice B rationale:
This is the correct answer. A bowel training program aims to help the patient regain control over their bowel movements. Taking the patient to the bathroom when they have the urge to defecate aligns with this goal. It allows the patient to respond to their body’s signals, which can help improve their confidence and independence over time.
Choice C rationale:
Taking the patient to the bathroom immediately before meals is not the most effective strategy for a bowel training program. While it’s true that eating can stimulate bowel movements due to the gastrocolic reflex, this approach does not consider the patient’s comfort or individual needs. It may also disrupt the patient’s enjoyment of their meals.
Choice D rationale:
Waiting until the patient feels abdominal cramping is not the most effective strategy for a bowel training program. Abdominal cramping can be a sign of constipation or other digestive issues. It’s important to address these issues separately and not rely on them as indicators for when to take the patient to the bathroom.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.
Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.
Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.
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