A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating.
What action should the nurse take?
Plan to administer insulin to the client.
Have the client breathe into a paper bag.
Plan to administer sodium bicarbonate to the client.
Have the client place their head between their knees.
The Correct Answer is B
Choice A rationale:
Administering insulin to a client who is hyperventilating due to respiratory alkalosis would not be the appropriate action. Insulin is used to lower blood glucose levels in clients with hyperglycemia, such as those with diabetes mellitus. It does not directly address the issues of hyperventilation or respiratory alkalosis.
Choice B rationale:
Having the client breathe into a paper bag is the correct action in this case. When a person hyperventilates, they exhale more carbon dioxide (CO2) than they produce. This can lead to a state of respiratory alkalosis, where the blood becomes too alkaline due to the low levels of CO2. By breathing into a paper bag, the client re-inhales some of the exhaled CO2, helping to restore the balance of gases in the blood and alleviate the symptoms of respiratory alkalosis.
Choice C rationale:
Administering sodium bicarbonate to a client who is hyperventilating and has respiratory alkalosis would not be the appropriate action. Sodium bicarbonate is an alkalinizing agent used to treat conditions where there is too much acid in the body, such as metabolic acidosis. In this case, the client’s body is too alkaline due to the respiratory alkalosis, so administering an alkalinizing agent would exacerbate the condition.
Choice D rationale:
Having the client place their head between their knees would not be the appropriate action for a client who is hyperventilating due to respiratory alkalosis. This position is often used to help alleviate symptoms of dizziness or fainting, but it does not address the underlying issue of the imbalance of gases in the blood due to hyperventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Wheezing is a common symptom of an allergic transfusion reaction. An allergic transfusion reaction occurs when the recipient’s immune system reacts to foreign proteins or allergens in the donor’s blood. Symptoms of an allergic reaction can range from mild to severe, and they typically include skin reactions such as hives and itching, as well as respiratory symptoms like wheezing. In severe cases, the reaction can cause difficulty breathing.
Choice B rationale:
Flank pain is not typically associated with an allergic transfusion reaction. It is more commonly a symptom of conditions affecting the kidneys or urinary tract. While flank pain can occur in a hemolytic transfusion reaction due to the rapid destruction of red blood cells, it is not a symptom of an allergic reaction.
Choice C rationale:
Elevated blood pressure is not a typical symptom of an allergic transfusion reaction. Allergic reactions more commonly cause symptoms such as hives, itching, and respiratory symptoms like wheezing. In severe cases, an allergic reaction can actually lead to a drop in blood pressure.
Choice D rationale:
Distended neck veins are not a typical symptom of an allergic transfusion reaction. They are more commonly associated with conditions that cause increased pressure in the right side of the heart. While distended neck veins can occur in a transfusion reaction due to fluid overload, they are not a symptom of an allergic reaction.
Correct Answer is C
Explanation
Choice A rationale:
Hypertension is not typically a sign of hypokalemia. Hypokalemia, or low potassium levels, can cause symptoms like fatigue, muscle weakness, digestive problems, and frequent urination. Hypertension, or high blood pressure, is not commonly associated with hypokalemia.
Choice B rationale:
Cerebral edema, or swelling in the brain, is not a common symptom of hypokalemia. Hypokalemia is more likely to cause symptoms related to muscle function and digestion, as potassium is an essential mineral that helps regulate muscle contractions, maintain healthy nerve function, and regulate fluid balance.
Choice C rationale:
Muscle weakness is a common symptom of hypokalemia. Potassium helps regulate muscle contractions. When blood potassium levels are low, your muscles produce weaker contractions. This can result in symptoms like muscle weakness and fatigue.
Choice D rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. Hypokalemia can cause digestive problems, but these are more likely to be issues like constipation rather than increased bowel sounds.
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