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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: A heart murmur is a common finding in clients who have mitral valve stenosis. It is a sound produced by turbulent blood flow through the narrowed valve. The murmur is usually heard as a low-pitched rumbling sound during diastole.

Choice B reason: Bradycardia is not a typical finding in clients who have mitral valve stenosis. Bradycardia is a slow heart rate, usually below 60 beats per minute. Mitral valve stenosis can cause tachycardia, which is a fast heart rate, due to increased cardiac workload and reduced cardiac output.

Choice C reason: Clubbing of the fingers is not a sign of mitral valve stenosis. Clubbing is a deformity of the fingertips and nails that occurs due to chronic hypoxia. Mitral valve stenosis can cause pulmonary hypertension and pulmonary edema, which can impair gas exchange, but not to the extent of causing clubbing.

Choice D reason: Barrel chest is not a sign of mitral valve stenosis. Barrel chest is a condition where the chest is enlarged and rounded due to chronic lung disease. Mitral valve stenosis can affect the lungs by increasing the pressure in the pulmonary circulation, but it does not cause structural changes in the chest wall.

A. Obtain a prescription to administer insulin. B. Obtain a prescription for supplemental oxygen. C. Obtain a prescription to check the client's glucose level. D. Obtain a prescription to administer intravenous fluids.

Correct Answer is B

Explanation

Choice A reason: Obtaining a prescription to administer insulin is an important action for the nurse to take, as insulin helps to lower the blood glucose level and reverse the metabolic acidosis caused by diabetic ketoacidosis. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.

Choice B reason: Obtaining a prescription for supplemental oxygen is the first action the nurse should take, as hypoxia is a life-threatening condition that can lead to tissue damage, organ failure, and death. The nurse should provide oxygen therapy to improve the client's oxygen saturation and prevent further complications.

Choice C reason: Obtaining a prescription to check the client's glucose level is a necessary action for the nurse to take, as glucose monitoring helps to evaluate the client's response to insulin therapy and guide further interventions. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.

Choice D reason: Obtaining a prescription to administer intravenous fluids is a beneficial action for the nurse to take, as fluid replacement helps to correct the dehydration, electrolyte imbalance, and hypotension caused by diabetic ketoacidosis. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.

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A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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