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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hydration and urine output are maintained through IV fluids and kidney function, not bladder irrigation.
B. Continuous bladder irrigation prevents catheter obstruction by flushing out blood clots or debris after TURP surgery. This is the primary purpose of the procedure.
C. While bladder irrigation may help reduce bleeding indirectly by maintaining flow, it is not its main purpose.
D. Antibiotics are not typically administered via bladder irrigation; systemic routes are preferred for infection control.
Correct Answer is D
Explanation
A. Multiple abdominal drains increase infection risk.
B. Cellulitis poses a high risk of infection.
C. Viral pneumonia is contagious and poses a high infection risk.
D. Chronic heart failure does not pose an infection risk, making this the safest roommate choice.
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