A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take first?
Place the client on continuous cardiac monitoring.
Obtain a prescription for insulin for the client.
Plan to administer sodium bicarbonate to the client.
Have the client breathe into a paper bag.
The Correct Answer is A
The correct answer is: A. Place the client on continuous cardiac monitoring.
Choice A reason:
Placing the client on continuous cardiac monitoring is crucial because metabolic alkalosis can lead to life-threatening arrhythmias due to electrolyte imbalances, particularly hypokalemia. Continuous monitoring allows for the early detection and management of these arrhythmias, ensuring patient safety.
Choice B reason:
Obtaining a prescription for insulin is not relevant for treating metabolic alkalosis. Insulin is typically used for managing hyperglycemia and diabetic ketoacidosis, not for correcting alkalosis.
Choice C reason:
Planning to administer sodium bicarbonate is incorrect because sodium bicarbonate is used to treat metabolic acidosis, not alkalosis. Administering it in this context could worsen the alkalosis.
Choice D reason:
Having the client breathe into a paper bag is a technique used for respiratory alkalosis to increase CO2 levels. It is not appropriate for metabolic alkalosis, which requires different management strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
Correct Answer is B
Explanation
Choice A reason: Collecting urine from the catheter's port is not a correct action for the nurse to take, as it can introduce contamination and infection into the urinary tract. The nurse should insert a new, sterile catheter into the bladder and collect the urine directly from the catheter.
Choice B reason: Using a sterile specimen container is a correct action for the nurse to take, as it ensures that the urine sample is not contaminated by any bacteria or other substances. The nurse should label the container with the client's name, date, and time of collection and send it to the laboratory as soon as possible.
Choice C reason: Using sterile water to inflate the balloon is not a relevant action for the nurse to take, as it applies to an indwelling catheter, not a straight catheter. A straight catheter does not have a balloon and is removed after the urine is drained.
Choice D reason: Instructing the client to clean from front to back with an antiseptic solution is a good action for the nurse to take, as it helps to prevent the introduction of bacteria from the anal area into the urethra. However, it is not the best answer, as it is a general hygiene measure, not a specific action for obtaining a urine specimen.
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