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 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.
Correct Answer is B
Explanation
Choice A rationale:
Tachycardia, or a rapid heart rate, is not typically an adverse effect of oxygen therapy. Oxygen therapy is often used to help people with conditions like COPD, COVID-19, emphysema, and sleep apnea get enough oxygen to function and stay well. While tachycardia can be a symptom of these conditions, it is not directly caused by the oxygen therapy itself.
Choice B rationale:
Cracks in the oral mucous membranes can indeed be an adverse effect of oxygen therapy. Oxygen therapy involves the delivery of highly concentrated oxygen, which can cause irritation and dryness in the airways, including the oral mucous membranes. This can lead to cracks and discomfort in the mouth. Therefore, it’s important for healthcare providers to monitor patients receiving oxygen therapy for signs of this adverse effect.
Excessive pulmonary secretions are not typically a direct adverse effect of oxygen therapy. While conditions that often require oxygen therapy, such as pneumonia and COPD, can lead to increased pulmonary secretions, these are symptoms of the underlying disease rather than the oxygen therapy itself.
Choice D rationale:
Poor skin turgor is not typically an adverse effect of oxygen therapy. Skin turgor refers to the elasticity of the skin, and poor skin turgor is often a sign of dehydration. While oxygen therapy can cause dryness of the mucous membranes, it does not typically affect the hydration status of the skin.
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