The nurse is caring for a client who has developed metabolic alkalosis. Which intervention would be a priority for the nurse to implement?

Assess for decreased respiratory rate

Diet teaching to include low protein foods

Obtain daily weight

Check blood glucose

Answer and Explanation

The Correct Answer is A

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's essential to address this condition promptly.

a. Assess for decreased respiratory rate: Metabolic alkalosis leads to hypoventilation as the body compensates by retaining carbon dioxide. Monitoring respiratory rate is crucial to detect any signs of respiratory distress or inadequate ventilation¹.

- Priority: High

b. Diet teaching to include low protein foods: While dietary adjustments are important, addressing the underlying cause (such as vomiting, diuretic use, or excessive alkali intake) is more critical. Low protein foods alone won't correct metabolic alkalosis.

- Priority: Low

c. Obtain daily weight: Daily weight monitoring is essential for assessing fluid balance, but it doesn't directly address metabolic alkalosis. Other interventions take precedence.

- Priority: Medium.

d. Check blood glucose: Blood glucose levels are not directly related to metabolic alkalosis. Focusing on acid-base balance and electrolyte levels is more relevant.

- Priority: Low

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Correct Answer is A

Explanation

a. Serum potassium 3.1 mEq/L (3.5-5.0 mEq/L): Furosemide (a loop diuretic) can cause potassium loss (hypokalemia). A potassium level of 3.1 mEq/L is below the normal range, and administering Furosemide could further decrease potassium levels. The nurse should question giving the medication and consider potassium supplementation.

b. Patient reports abdominal pain:Abdominal pain is not directly related to Furosemide administration. While it's essential to assess the cause of pain, it doesn't specifically impact the decision to administer Furosemide.

c. Patient does not have a foley catheter: The absence of a foley catheter is not a contraindication for Furosemide administration. It's unrelated to the medication's safety or effectiveness.

d. Blood pressure 132/70: The blood pressure reading falls within a normal range. Furosemide is commonly used to manage hypertension and fluid overload in heart failure patients. This blood pressure reading does not raise concerns about administering Furosemide.

A. Review I&O B. Check pulse oximetry C. Administer digoxin D. Obtain 12-lead ECG

Correct Answer is B

Explanation

a. Review I&O (Intake and Output): While reviewing intake and output is an essential component of assessing fluid status in heart failure, it is not the immediate priority in this scenario. The client's presentation with dyspnea and crackles suggests acute respiratory distress, which requires immediate assessment and intervention to address potential hypoxemia.

b. Check pulse oximetry: In a client presenting with elevated blood pressure, dyspnea, and bilateral crackles throughout lung fields, the priority intervention is to assess oxygenation status. Checking pulse oximetry provides immediate information about the client's oxygen saturation levels, which is crucial for determining the severity of respiratory distress and guiding subsequent interventions. Hypoxemia is a common complication in heart failure exacerbations and can worsen symptoms such as dyspnea and respiratory distress.

c. Administer digoxin: Digoxin is a medication commonly used in the management of heart failure to improve cardiac output and reduce heart rate. However, it is not the priority intervention in this scenario. Assessing oxygenation status and addressing respiratory distress take precedence over administering medications.

d. Obtain 12-lead ECG: While obtaining a 12-lead ECG is important for assessing cardiac rhythm and identifying any potential cardiac abnormalities, it is not the immediate priority in this scenario. The client's presentation with acute respiratory distress warrants immediate assessment of oxygenation status to guide appropriate interventions.

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The nurse is caring for a client who has developed metabolic alkalosis. Which intervention would be a priority for the nurse to implement?

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The nurse is caring for a client who has developed metabolic alkalosis. Which intervention would be a priority for the nurse to implement?