An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to:

pant with mouth open

sit up

lie down

breathe through a re-breather mask

Answer and Explanation

The Correct Answer is B

Choice A reason: Panting with mouth open is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the risk of hyperventilation and respiratory alkalosis, which could worsen the anxiety and cause symptoms such as dizziness, tingling, and muscle spasms.

Choice B reason: Sitting up is an appropriate intervention for an anxious patient with a high respiratory rate. This could help the patient relax and breathe more deeply and slowly, which could reduce the anxiety and normalize the blood gas levels.

Choice C reason: Lying down is not an appropriate intervention for an anxious patient with a high respiratory rate. This could make the patient feel more claustrophobic and increase the anxiety and the respiratory rate.

Choice D reason: Breathing through a re-breather mask is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the oxygen concentration in the blood, which could reduce the stimulus for breathing and cause respiratory depression.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high HCO3-. The patient's pH and HCO3- are both low, indicating acidosis, not alkalosis.

Choice B reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2. The patient's pH is low and PaCO2 is normal, indicating a metabolic problem, not a respiratory one.

Choice C reason: This is incorrect because respiratory acidosis is characterized by a low pH and a high PaCO2. The patient's pH is low, but PaCO2 is normal, indicating a metabolic problem, not a respiratory one.

Choice D reason: This is correct because metabolic acidosis is characterized by a low pH and a low HCO3-. The patient's pH and HCO3- are both low, indicating a metabolic disorder. The condition is uncompensated because the PaCO2 is normal, meaning the respiratory system is not compensating for the metabolic acidosis.

A. The client with an ileostomy B. The client with cirrhosis C. The client with heart failure D. The client with decreased renal function

Correct Answer is A

Explanation

Choice A reason: The client with an ileostomy is at risk for fluid volume deficit because an ileostomy is a surgical opening in the ileum, the last part of the small intestine, that allows the drainage of intestinal contents. This can result in a loss of fluids and electrolytes, especially sodium and potassium, which can lead to dehydration and hypovolemia.

Choice B reason: The client with cirrhosis is not at risk for fluid volume deficit, but rather fluid volume excess. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. This can lead to portal hypertension, which is an increase in the pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause ascites, which is the accumulation of fluid in the abdominal cavity, and edema, which is the swelling of the tissues due to fluid retention.

Choice C reason: The client with heart failure is not at risk for fluid volume deficit, but rather fluid volume excess. Heart failure is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to congestion of the blood vessels, which can cause pulmonary edema, which is the accumulation of fluid in the lungs, and peripheral edema, which is the swelling of the extremities due to fluid retention.

Choice D reason: The client with decreased renal function is not at risk for fluid volume deficit, but rather fluid volume excess. Decreased renal function is a condition where the kidneys are unable to filter the blood and remove excess fluids and wastes. This can lead to oliguria, which is a decrease in urine output, and anuria, which is the absence of urine output. This can cause fluid overload, which can affect the heart and the lungs.

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An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to:

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Naxlex Comprehensive Predictor Exams

Lena Mason, who has diabetes, is admitted in a stuporous condition. Her blood gases show a pH of 7.33, PaCO2 of 40 mm Hg, and HCO3- of 20 mEq/L. What type of acid-base imbalance does this patient have?

Correct Answer is D

Explanation

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?

Correct Answer is A

Explanation

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