The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?
Encourage the patient to breathe in and out slowly into a paper bag.
Immediately administer oxygen via a mask and monitor oxygen saturation.
Anticipate the administration of intravenous sodium bicarbonate.
Prepare to start an intravenous fluid bolus using isotonic fluids.
The Correct Answer is A
The correct answer is choice A: Encourage the patient to breathe in and out slowly into a paper bag.
Choice A rationale: The patient’s arterial blood gas (ABG) results indicate respiratory alkalosis, as evidenced by the elevated pH (7.48) and decreased PaCO2 (25 mm Hg). Respiratory alkalosis often results from hyperventilation, which can occur due to anxiety. Breathing into a paper bag helps to increase CO2 levels in the blood, thereby correcting the alkalosis.
Choice B rationale: Administering oxygen is not appropriate in this scenario because the patient’s PaO2 is already elevated (110 mm Hg), indicating that oxygenation is not the issue. Providing additional oxygen would not address the underlying problem of hyperventilation and respiratory alkalosis.
Choice C rationale: Intravenous sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. In this case, the patient’s HCO3 is within the normal range (24 mEq/L), indicating that there is no metabolic acidosis present.
Choice D rationale: Starting an intravenous fluid bolus with isotonic fluids is not indicated for correcting respiratory alkalosis. This intervention is more appropriate for patients experiencing hypovolemia or dehydration, which is not suggested by the patient’s ABG results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
The patient's tachycardia, pale, cool skin, and decreased urine output are signs of the body's natural compensatory mechanisms in response to fluid volume deficit. When the body
experiences a decrease in fluid volume, it tries to compensate by increasing heart rate (tachycardia) to maintain blood flow to vital organs and constricting blood vessels to preserve fluid and maintain blood pressure. Pale, cool skin is a result of vasoconstriction, and decreased urine output is a way the body conserves water during dehydration.
Choice A rationale:
Effects of rapidly infused intravenous fluids are not the cause of the patient's current findings. In fact, the nurse's notes indicate that the IV fluid therapy (0.9% sodium chloride) was initiated at 125 mL/hr, which is a relatively standard and cautious rate. Rapidly infused fluids could potentially cause fluid overload, but that is not the situation here.
Choice C rationale:
Pharmacological effects of a diuretic are not relevant to this patient's presentation. There is no mention of diuretic use in the nurse's notes, and the symptoms presented are more consistent with fluid volume deficit and dehydration rather than diuretic use.
Choice D rationale:
Cardiac failure is not the correct answer, as there is no indication of heart failure in the patient's presentation or nurse's notes. The symptoms and findings described are more indicative of fluid volume deficit, which is not synonymous with cardiac failure.
Correct Answer is D
Explanation
Digoxin. Choice A rationale:
Potassium chloride (KCL) is a supplement used to treat or prevent low potassium levels. While it can have side effects, visual disturbances are not typically associated with KCL. Therefore, it is not the medication the nurse suspects to be causing the problem.
Choice B rationale:
Warfarin (Coumadin) is an anticoagulant used to prevent blood clot formation. Visual disturbances are not a known side effect of warfarin. Therefore, it is unlikely to be the cause of the patient's symptoms.
Choice C rationale:
Aspirin (ASA) is a pain reliever and antiplatelet medication, and while it can cause visual disturbances in some cases, it is not a common or significant side effect. Aspirin is also not specifically linked to atrial fibrillation.
Choice D rationale:
Digoxin (Lanoxin) is used to treat atrial fibrillation and heart failure. Visual disturbances are a known side effect of digoxin toxicity. Given the patient's diagnosis of atrial fibrillation and the reported symptoms, the nurse suspects the problem lies with digoxin and should further investigate and report to the provider.
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