A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?
Plan to administer insulin to the client.
Plan to administer sodium bicarbonate to the client.
Have the client breath into a paper bag
Have the client place their head between their knees.
The Correct Answer is C
A. Plan to administer insulin to the client: Insulin is not indicated for respiratory alkalosis; it is used for managing hyperglycemia in diabetic patients.
B. Plan to administer sodium bicarbonate to the client: Sodium bicarbonate is not appropriate for respiratory alkalosis and could worsen the condition.
C. Have the client breathe into a paper bag: Breathing into a paper bag can help increase carbon dioxide levels in the blood, which is often helpful in treating respiratory alkalosis due to hyperventilation.
D. Have the client place their head between their knees: This position does not directly address hyperventilation or help regulate breathing.
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Correct Answer is C
Explanation
A. "It's okay for my child to have plenty of ice cream.": Cold, soft foods like ice cream are typically allowed, but dairy products like ice cream may increase mucus production, which could irritate the throat.
B. “I’ll help my child gargle with salt water a few times a day.": Gargling is contraindicated after a tonsillectomy as it can irritate the surgical site and potentially cause bleeding.
C. "I'll call the doctor if my child is swallowing continuously." Continuous swallowing can be a sign of bleeding after a tonsillectomy, which is a medical emergency. It is important for parents to recognize this as an early sign of hemorrhage.
D. "It's okay for my child to ride his bike in a few days.": Strenuous activities, including riding a bike, should be avoided for at least 1-2 weeks to reduce the risk of bleeding.
Correct Answer is A
Explanation
A. Continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber indicates a possible air leak in the system, which needs to be assessed and potentially reported to the charge nurse for further evaluation.
B. Patient respiratory status is stable and denies pain to chest tube site: This is a normal finding and does not require reporting.
C. Tidalling, fluctuations in the fluid level in the water-seal chamber: This is a normal finding, indicating that the chest tube is functioning properly and that the lungs are expanding.
D. Occasional bubbling in the water-seal chamber: This may be acceptable, especially with respiratory movements, as it could indicate that the patient is exhaling, but continuous bubbling is concerning.