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: Doing wheelchair exercises sitting in the chair is a correct statement, as it helps to prevent pressure ulcers, improve circulation, and maintain muscle tone.
Choice B reason: Using a suppository every night to have a bowel movement is an incorrect statement, as it indicates a dependence on laxatives and a lack of bowel training. The adolescent should be taught to establish a regular bowel routine, use natural methods such as abdominal massage and digital stimulation, and avoid overuse of laxatives.
Choice C reason: Needing to catheterize oneself twice a day is a correct statement, as it helps to prevent urinary tract infections, bladder distension, and kidney damage.
Choice D reason: Carrying a water bottle with me because I drink a lot of water is a correct statement, as it helps to prevent dehydration, constipation, and urinary tract infections.
Correct Answer is C
Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
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