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 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.

A. "I am glad that these tubes will fall out at home when I finally shower." B. "I should measure the drainage each day to make sure it is less than an ounce (30 mL)." C. "I should be careful how I lie in bed so that I will not kink the tubing." D. "If there is a foul odor from the drainage, I will contact my primary health care provider."

Correct Answer is A

Explanation

A. This statement indicates that the client may not fully understand the care required for the drainage tubes. Drainage tubes typically do not "fall out" on their own; they need to be removed by a healthcare provider. The client should be instructed to care for the tubes, monitor drainage, and report any concerns to their healthcare provider.

B. It is appropriate to measure the drainage each day and report it if it exceeds the expected amount. This helps ensure that the surgical site is healing properly.

C. The client should be cautious with the positioning of the drainage tubes to avoid kinking or pulling, which could interfere with drainage and cause complications.

D. A foul odor from the drainage could indicate an infection, so it is appropriate for the client to contact their primary healthcare provider if this occurs.

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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

Which information about continuous bladder irrigation will the nurse teach to a client who is being admitted for a transurethral resection of the prostate (TURP)?

Correct Answer is B

Explanation

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Correct Answer is A

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