A nurse in the community clinic is providing care to a client who is anxious and hyperventilating. What should the nurse do to reduce the risk of respiratory alkalosis?

Have the place a plastic bag over their head and breathe.

Teach the client breathing techniques that focus on breathing and relaxing

Position the client in a high-Fowler position.

Encourage the client to try to remain calm.

Answer and Explanation

The Correct Answer is B

A. Having the client place a plastic bag over their head is dangerous and should never be done.

B. Teaching breathing techniques, such as diaphragmatic breathing or using a paper bag, helps the client retain more carbon dioxide and can prevent respiratory alkalosis.

C. Positioning the client in a high-Fowler position may be helpful for breathing but does not address hyperventilation or respiratory alkalosis directly.

D. While encouraging the client to remain calm may help, it is not as effective as teaching specific breathing techniques.

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Correct Answer is C

Explanation

A. Sticking out the tongue assesses cranial nerve XII (hypoglossal nerve), not XI.

B. Following an object with the eyes assesses cranial nerves III, IV, and VI, not XI.

C. Cranial nerve XI (the accessory nerve) controls the sternocleidomastoid and trapezius muscles, and testing involves shoulder shrugging and head rotation against resistance.

D. Hearing normally assesses cranial nerve VIII (vestibulocochlear nerve).

A. Stage III B. unstageable C. necrotic stage I D. stage II

Correct Answer is B

Explanation

A. Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue.
B. The above image depicts an Unstageable pressure ulcers since the base of the ulcer is covered by slough in the wound bed.
C. The term 'necrotic stage I' is not typically used in the staging of pressure ulcers. Necrosis refers to dead tissue, which is not present in a Stage I pressure ulcer. Stage I ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

D. Stage II pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured blister. The ulcer is painful and may appear as a shiny or dry shallow ulcer without slough or bruising.

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A nurse in the community clinic is providing care to a client who is anxious and hyperventilating. What should the nurse do to reduce the risk of respiratory alkalosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While conducting a focused neurological assessment, the nurse includes testing the function of cranial nerve XI in a client. What assessment findings indicate the nerve is intact and functioning?

Correct Answer is C

Explanation

The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

Correct Answer is B

Explanation

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