A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The arterial blood gas values are pH 6.88, PaO2 50 mmHg PaCO2 60 mmHg, and HCO3 22mEq/L. Which action should the nurse take first?
Administer 50mL of sodium bicarbonate IV
Apply oxygen by mask or nasal cannula
Apply a paper bag over the client's nose and mouth
Administer 50mL of 20% glucose and 20 units of regular insulin IV
The Correct Answer is B
Rationale:
A. Sodium bicarbonate may be used to correct acidosis, but oxygenation must be addressed first to prevent further deterioration.
B. The first priority is to improve oxygenation. Administering oxygen by mask or nasal cannula is the most immediate and effective way to increase PaO₂ and support respiratory function.
C. A paper bag is used for respiratory alkalosis, not acidosis—it would worsen hypoxemia.
D. Glucose and insulin are used for hyperkalemia, which is not the current priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Sodium bicarbonate may be used to correct acidosis, but oxygenation must be addressed first to prevent further deterioration.
B. The first priority is to improve oxygenation. Administering oxygen by mask or nasal cannula is the most immediate and effective way to increase PaO₂ and support respiratory function.
C. A paper bag is used for respiratory alkalosis, not acidosis—it would worsen hypoxemia.
D. Glucose and insulin are used for hyperkalemia, which is not the current priority.
Correct Answer is A
Explanation
Rationale:
A. Chvostek’s sign is a clinical indicator of hypocalcemia. It is elicited by tapping the facial nerve in front of the ear, which causes twitching of the facial muscles in clients with low calcium levels due to increased neuromuscular excitability.
B. Brudzinski’s sign indicates meningeal irritation, such as in meningitis, not hypocalcemia.
C. Cullen’s sign is bruising around the umbilicus, associated with intra-abdominal bleeding, not electrolyte imbalance.
D. Kernig’s sign is another sign of meningeal irritation and is unrelated to calcium levels.
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