A client has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas results: pH 7.12, HCO3 22 mEq/L, PaCO2 55 mmHg, PaO2 60 mmHg. Which intervention is the most appropriate?

Apply a paper bag over the clients nose and mouth.

Administer 50 mL of 20% glucose and 20 units of regular insulin.

Administer 50 mL of sodium bicarbonate intravenously.

Apply oxygen by mask or nasal cannula.

Answer and Explanation

The Correct Answer is D

A. Appling a paper bag over the client's nose and mouth is used for hyperventilation or respiratory alkalosis, not for respiratory acidosis. In this case, it would worsen the client’s condition by increasing CO2 retention.

B. Administering 50 mL of 20% glucose and 20 units of regular insulin is appropriate for hyperkalemia or diabetic ketoacidosis, not respiratory acidosis following a seizure.

C. Administering 50 mL of sodium bicarbonate intravenously is used for severe metabolic acidosis. This client’s acidosis is primarily respiratory in origin, making this choice inappropriate.

D. Applying oxygen by mask or nasal cannula helps correct the low oxygen levels and supports respiration post-seizure.

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Correct Answer is A

Explanation

A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.

B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.

C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.

D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.

A. Assess oral temperature. B. Place on cardiac monitor. C. Check a potassium level. D. Assess for pain at contact points.

Correct Answer is B

Explanation

A. Assessing oral temperature is not a priority immediately after an electrical burn, as the focus should be on monitoring for cardiac issues and other life-threatening conditions.

B. Electrical burns can cause cardiac arrhythmias, including dysrhythmias like ventricular fibrillation, which can be life-threatening. The nurse should place the client on a cardiac monitor immediately to detect any abnormal rhythms and respond accordingly.

C. While checking potassium levels is important for assessing potential complications such as kidney damage or arrhythmias, cardiac monitoring should take precedence.

D. Assessing for pain at contact points is important, but it is secondary to ensuring cardiac stability in an electrical burn victim.

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A client has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas results: pH 7.12, HCO3 22 mEq/L, PaCO2 55 mmHg, PaO2 60 mmHg. Which intervention is the most appropriate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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