An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to:
pant with mouth open
sit up
lie down
breathe through a re-breather mask
The Correct Answer is B
Choice A reason: Panting with mouth open is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the risk of hyperventilation and respiratory alkalosis, which could worsen the anxiety and cause symptoms such as dizziness, tingling, and muscle spasms.
Choice B reason: Sitting up is an appropriate intervention for an anxious patient with a high respiratory rate. This could help the patient relax and breathe more deeply and slowly, which could reduce the anxiety and normalize the blood gas levels.
Choice C reason: Lying down is not an appropriate intervention for an anxious patient with a high respiratory rate. This could make the patient feel more claustrophobic and increase the anxiety and the respiratory rate.
Choice D reason: Breathing through a re-breather mask is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the oxygen concentration in the blood, which could reduce the stimulus for breathing and cause respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Stroke is not a cause of hyponatremia, but rather a possible complication of it. Hyponatremia is a condition where the sodium level in the blood is too low, which can affect the brain function and cause symptoms such as confusion, seizures, or coma. Stroke is a condition where the blood supply to a part of the brain is interrupted, which can cause brain damage and neurological deficits.
Choice B reason: Dehydration is not a cause of hyponatremia, but rather a cause of hypernatremia. Dehydration is a condition where the body loses more fluids than it takes in, which can affect the blood volume and the electrolyte balance. Dehydration can cause hypernatremia, which is a condition where the sodium level in the blood is too high, which can also affect the brain function and cause symptoms such as thirst, dry mouth, or lethargy.
Choice C reason: Increased secretion of aldosterone is not a cause of hyponatremia, but rather a cause of hypokalemia. Aldosterone is a hormone that regulates the sodium and potassium levels in the body by increasing the reabsorption of sodium and the excretion of potassium in the kidneys. Increased secretion of aldosterone can cause hypokalemia, which is a condition where the potassium level in the blood is too low, which can affect the muscle and nerve function and cause symptoms such as weakness, cramps, or arrhythmias.
Choice D reason: Congestive heart failure (CHF) is a cause of hyponatremia, as it is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to fluid retention and edema, which can dilute the sodium level in the blood and cause hyponatremia. CHF can also stimulate the release of antidiuretic hormone (ADH), which increases the reabsorption of water in the kidneys and further lowers the sodium level in the blood.
Correct Answer is D
Explanation
Choice A reason: Respiratory alkalosis is caused by hyperventilation, which lowers the carbon dioxide levels in the blood and raises the pH. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice B reason: Metabolic acidosis is caused by an excess of acids or a loss of bases in the body, which lowers the pH. This can occur in conditions such as diabetic ketoacidosis, renal failure, or diarrhea. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice C reason: Respiratory acidosis is caused by hypoventilation, which raises the carbon dioxide levels in the blood and lowers the pH. This can occur in conditions such as chronic obstructive pulmonary disease, asthma, or sedative overdose. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice D reason: Metabolic alkalosis is caused by a loss of acids or an excess of bases in the body, which raises the pH. This can occur in conditions such as vomiting, gastric suction, or diuretic use. This is the most likely acid-base disorder to occur in a client with a nasogastric tube on low suction, as the tube removes gastric acid from the stomach.
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