A nurse is caring for a patient with metabolic alkalosis.
What actions should the nurse take?
Place the patient on continuous cardiac monitoring.
Obtain a prescription for insulin for the patient.
Plan to administer sodium bicarbonate to the patient.
Have the patient breathe into a paper bag.
The Correct Answer is A
Choice A rationale:
Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It causes metabolic, respiratory, and renal responses, producing characteristic symptoms. One of the manifestations of metabolic alkalosis is cardiovascular abnormalities, such as atrial tachycardia. Therefore, placing the patient on continuous cardiac monitoring is a necessary action to assess the patient’s heart rate and rhythm and detect any abnormalities early.
Choice B rationale:
Insulin is not typically used in the treatment of metabolic alkalosis. Insulin is a hormone that regulates blood sugar levels. It’s not directly related to the body’s acid-base balance. Therefore, obtaining a prescription for insulin for the patient would not be a relevant action in this case.
Choice C rationale:
Administering sodium bicarbonate to a patient with metabolic alkalosis would not be appropriate. Sodium bicarbonate is a base and is often used to treat metabolic acidosis, a condition characterized by an excess of acid in the body. Giving sodium bicarbonate to a patient with metabolic alkalosis, a condition characterized by an excess of base in the body, could potentially worsen the patient’s condition.
Choice D rationale:
Having the patient breathe into a paper bag is a common treatment for respiratory alkalosis, not metabolic alkalosis.
Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide in the blood. Breathing into a paper bag helps to increase the amount of carbon dioxide the person inhales, helping to restore the acid-base balance. However, metabolic alkalosis is not caused by hyperventilation, so this treatment
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
Correct Answer is A
Explanation
Choice A rationale:
Wheezing is a common symptom of an allergic transfusion reaction. An allergic transfusion reaction occurs when the recipient’s immune system reacts to foreign proteins or allergens in the donor’s blood. Symptoms of an allergic reaction can range from mild to severe, and they typically include skin reactions such as hives and itching, as well as respiratory symptoms like wheezing. In severe cases, the reaction can cause difficulty breathing.
Choice B rationale:
Flank pain is not typically associated with an allergic transfusion reaction. It is more commonly a symptom of conditions affecting the kidneys or urinary tract. While flank pain can occur in a hemolytic transfusion reaction due to the rapid destruction of red blood cells, it is not a symptom of an allergic reaction.
Choice C rationale:
Elevated blood pressure is not a typical symptom of an allergic transfusion reaction. Allergic reactions more commonly cause symptoms such as hives, itching, and respiratory symptoms like wheezing. In severe cases, an allergic reaction can actually lead to a drop in blood pressure.
Choice D rationale:
Distended neck veins are not a typical symptom of an allergic transfusion reaction. They are more commonly associated with conditions that cause increased pressure in the right side of the heart. While distended neck veins can occur in a transfusion reaction due to fluid overload, they are not a symptom of an allergic reaction.
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