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 B
Explanation
A. Abdominal pain: This is not typically associated with respiratory alkalosis, which primarily affects respiratory and neurologic systems.
B. Hyperventilation: Respiratory alkalosis occurs when a person exhales too much carbon dioxide, typically from hyperventilation, which can result from anxiety, pain, or other conditions.
C. Constipation: This is not a symptom of respiratory alkalosis; it might be seen in other metabolic disorders but not this one.
D. Dry skin: Dry skin is not a common manifestation of respiratory alkalosis; symptoms are usually respiratory and neurological (e.g., lightheadedness, tingling).
Correct Answer is C
Explanation
A. Provide mouth care: Mouth care is important to prevent infection but is not the first priority in this procedure.
B. Position the client so that the lung area to be drained is above the client’s trachea: This is necessary for effective postural drainage, but auscultation should be done first to determine the area to drain.
C. Auscultate lung fields. Auscultating lung fields first helps to determine the location of secretions and identify which areas of the lungs need to be targeted during postural drainage and percussion.
D. Cup hands and tap on the client’s chest repeatedly: Chest percussion helps mobilize secretions, but it should be done after auscultation to target the correct areas.