A nurse is caring for a client who has an infected surgical wound on his abdomen. The nurse notes that the wound has redness, warmth, swelling, pain, and purulent drainage. The nurse recognizes these findings as indicative of what stage of inflammation?

Choice A reason:

Administering antiemetics as prescribed is an intervention that the nurse should implement for a client who has metabolic alkalosis due to prolonged vomiting. Antiemetics are medications that can prevent or treat nausea and vomiting, which are the main causes of metabolic alkalosis in this case. By stopping vomiting, antiemetics can help prevent further loss of gastric acid and bicarbonate retention, which can correct metabolic alkalosis.

Choice B reason:

Monitoring serum potassium levels is an intervention that the nurse should implement for a client who has metabolic alkalosis due to prolonged vomiting. Metabolic alkalosis can cause hypokalemia due to increased renal excretion of potassium and intracellular shift of potassium in exchange for hydrogen ions. Hypokalemia can worsen metabolic alkalosis by impairing renal acid excretion and increasing bicarbonate reabsorption. The nurse should monitor serum potassium levels regularly and report any abnormalities or signs of hypokalemia, such as muscle weakness, cramps, arrhythmias, or ECG changes.

Choice C reason:

Administering sodium bicarbonate IV as prescribed is not an intervention that the nurse should implement for a client who has metabolic alkalosis due to prolonged vomiting. Sodium bicarbonate is an alkalinizing agent that can increase serum bicarbonate levels and pH, which can worsen metabolic alkalosis. Sodium bicarbonate IV should be avoided or used with caution in clients who have metabolic alkalosis, unless they have severe acid-base imbalance or coexisting metabolic acidosis.

Choice D reason:

Encouraging intake of acidic foods and beverages is not an intervention that the nurse should implement for a client who has metabolic alkalosis due to prolonged vomiting. Acidic foods and beverages can lower the pH of the stomach, but they have little effect on the pH of the blood or urine, which are regulated by other mechanisms such as buffers, lungs, and kidneys. Acidic foods and beverages can also irritate the gastric mucosa and trigger more vomiting, which can aggravate metabolic alkalosis.

Choice E reason:

Providing supplemental oxygen as needed is an intervention that the nurse should implement for a client who has metabolic alkalosis due to prolonged vomiting. Metabolic alkalosis can cause respiratory compensation by decreasing the respiratory rate and depth, which can lead to hypoxemia and hypercapnia. Supplemental oxygen can help maintain adequate oxygenation and prevent tissue hypoxia and organ damage. The nurse should monitor the client's oxygen saturation and arterial blood gas levels and adjust the oxygen therapy accordingly.

Choice A reason:

Vascular stage is the stage of inflammation that involves the changes in blood flow and vascular permeability at the site of injury or infection. It manifests as redness and warmth due to vasodilation and increased blood flow, and swelling due to fluid leakage from the vessels into the interstitial space.

Choice B reason:

Cellular stage is the stage of inflammation that involves the migration of white blood cells from the vessels into the tissues to eliminate the causative agent and remove the damaged tissue. It manifests as pain due to the release of chemical mediators that stimulate nerve endings, and purulent drainage due to the accumulation of dead cells and microorganisms.

Choice D reason:

Resolution stage is the stage of inflammation that involves the restoration of normal tissue structure and function after the elimination of the causative agent and the removal of the damaged tissue. It manifests as decreased redness, warmth, swelling, pain, and drainage due to the cessation of inflammatory response.