A nurse is caring for a patient with metabolic alkalosis.
What actions should the nurse take?
Place the patient on continuous cardiac monitoring.
Obtain a prescription for insulin for the patient.
Plan to administer sodium bicarbonate to the patient.
Have the patient breathe into a paper bag.
The Correct Answer is A
Choice A rationale:
Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It causes metabolic, respiratory, and renal responses, producing characteristic symptoms. One of the manifestations of metabolic alkalosis is cardiovascular abnormalities, such as atrial tachycardia. Therefore, placing the patient on continuous cardiac monitoring is a necessary action to assess the patient’s heart rate and rhythm and detect any abnormalities early.
Choice B rationale:
Insulin is not typically used in the treatment of metabolic alkalosis. Insulin is a hormone that regulates blood sugar levels. It’s not directly related to the body’s acid-base balance. Therefore, obtaining a prescription for insulin for the patient would not be a relevant action in this case.
Choice C rationale:
Administering sodium bicarbonate to a patient with metabolic alkalosis would not be appropriate. Sodium bicarbonate is a base and is often used to treat metabolic acidosis, a condition characterized by an excess of acid in the body. Giving sodium bicarbonate to a patient with metabolic alkalosis, a condition characterized by an excess of base in the body, could potentially worsen the patient’s condition.
Choice D rationale:
Having the patient breathe into a paper bag is a common treatment for respiratory alkalosis, not metabolic alkalosis.
Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide in the blood. Breathing into a paper bag helps to increase the amount of carbon dioxide the person inhales, helping to restore the acid-base balance. However, metabolic alkalosis is not caused by hyperventilation, so this treatment
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Antinuclear antibody (ANA) titer is a blood test that detects the presence of antinuclear antibodies, which are autoantibodies that target the body's own tissues. These antibodies are often present in people with autoimmune diseases, including rheumatoid arthritis.
While a positive ANA test does not definitively diagnose rheumatoid arthritis, it can support a diagnosis when considered alongside other clinical findings and laboratory tests.
Choice B rationale:
Blood urea nitrogen (BUN) is a blood test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that is produced when the body breaks down proteins.
BUN levels can be elevated in people with kidney disease, dehydration, or certain other medical conditions. However, BUN is not specifically used to diagnose rheumatoid arthritis.
Choice C rationale:
Urinalysis is a test that examines the urine for various substances, including cells, bacteria, and chemicals.
It can be used to diagnose a variety of conditions, including urinary tract infections, kidney disease, and diabetes. However, urinalysis is not typically used to diagnose rheumatoid arthritis.
Choice D rationale:
Erythrocyte sedimentation rate (ESR) is a blood test that measures how quickly red blood cells settle at the bottom of a test tube.
A high ESR can indicate inflammation in the body.
ESR is often elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Choice E rationale:
White blood cell count (WBC) is a blood test that measures the number of white blood cells in the blood. White blood cells are part of the immune system and help fight infection.
A high WBC count can indicate an infection or inflammation.
WBC count can be elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Correct Answer is B
Explanation
Choice A rationale:
Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.
Choice B rationale:
After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.
Choice C rationale:
Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.
Choice D rationale:
Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.
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