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:
The statement “The pulse oximeter may not be accurate during periods of excessive movement” is correct. Pulse oximeters measure the amount of oxygen in the blood by shining light through the skin, and movement can cause the light to scatter, leading to inaccurate readings.
Choice B rationale:
The statement “We will inform the doctor if the pulse oximeter consistently reads 100%” indicates further instruction is needed. A pulse oximeter reading of 100% is not necessarily a cause for concern. It simply means that the hemoglobin is fully saturated with oxygen. However, if the oxygen level is consistently at 100%, it could indicate that the oxygen flow is too high and needs to be adjusted. It’s important to follow the healthcare provider’s instructions regarding the desired oxygen saturation level for the infant.
Choice C rationale:
The statement “The probe of the pulse oximeter can be attached to a finger or a toe” is correct. The probe of a pulse oximeter can indeed be attached to a finger, toe, or even an earlobe. The important thing is that it’s attached to a part of the body with good blood flow. Choice D rationale:
The statement “We will move the probe of the pulse oximeter every 24 hours” is correct. It’s important to move the probe periodically to prevent skin damage, such as pressure sores or burns, especially in infants who have delicate skin.
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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