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 C
Explanation
Choice A rationale:
The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.
Choice B rationale:
The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:
The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.
Choice D rationale:
The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.
Correct Answer is ["C"]
Explanation
The correct answer is Choice C.
Choice A rationale: Applying four drops of developing solution to each stool specimen is incorrect. Typically, the test requires two drops of solution. Following manufacturer instructions ensures accurate results and prevents unnecessary waste or inaccurate readings.
Choice B rationale: Using toilet paper to transfer the stool specimen is improper. Stool should be collected using the provided applicator stick to avoid contamination, ensuring the accuracy of the fecal occult blood test.
Choice C rationale: Waiting 30 seconds after applying the developing solution allows the chemical reaction to complete, ensuring accurate detection of any occult blood present in the stool sample.
Choice D rationale: Collecting two stool specimens from the same area increases the risk of missing occult blood present in different parts of the stool. Sampling from multiple areas enhances test accuracy and ensures comprehensive results.
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