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 D
Explanation
A. Decreasing respiratory rate: This is not expected; respiratory rate may increase as the body attempts to compensate for reduced oxygenation.
B. Facial flushing: This is not a common symptom of atelectasis and may indicate other issues such as anxiety or fever.
C. Dry cough: While a cough may be present, it is more likely to be productive due to retained secretions.
D. Increasing dyspnea: Atelectasis often leads to decreased lung volume, which can cause increasing dyspnea as the lung tissue collapses.
Correct Answer is B
Explanation
A. Perform chest physiotherapy prior to suctioning: While chest physiotherapy helps mobilize secretions, it does not thin them, which is the main concern in this situation.
B. Provide humidified oxygen. Humidified oxygen helps to moisten secretions, making them easier to expectorate or suction, which is especially important for tracheostomy care.
C. Pre-lubricate the suction catheter tip with sterile saline when suctioning the airway: This is not a method to thin secretions, but rather to lubricate the catheter.
D. Hyperventilate the client with 100% oxygen before suctioning the airway: This is done to prevent hypoxia during suctioning but does not help with thinning secretions.