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.
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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Related Questions
Correct Answer is B
Explanation
A. Base deficit (HCO3): Acidosis: A base deficit indicates metabolic acidosis, but respiratory acidosis is more likely with the high rate of ventilation.
B. Acid excess (CO2): Acidosis: This is the correct answer. A high respiratory rate can lead to hyperventilation, decreasing CO2 levels and causing respiratory alkalosis, which may be a concern with an elevated rate.
C. Base excess (HCO3): Alkalosis: This would indicate metabolic alkalosis, but it is not as related to ventilator settings.
D. Acid deficit (CO2): Alkalosis: If the CO2 level is too low due to hyperventilation, this can lead to alkalosis, which the nurse is questioning here.
Correct Answer is C
Explanation
A. Pouring water over the genitals can help reduce the pain of urination, which is common in clients with genital herpes.
B. Washing hands carefully after applying ointment is important to prevent the spread of the virus.
C. The herpes simplex virus can be transmitted even when lesions are not present, so this statement indicates a need for further education. The virus can be spread through asymptomatic viral shedding.
D. Increasing fluid intake when lesions are open helps to prevent urinary retention and promote healing.
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