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:
Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.
Choice B rationale:
After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.
Choice C rationale:
Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.
Choice D rationale:
Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
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