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. Case manager: A case manager can help coordinate care but is not responsible for the specific education on BiPAP use.
B. Occupational therapist: Occupational therapists focus on daily living activities, not respiratory therapy.
C. Physical therapist: Physical therapists work on mobility and musculoskeletal issues, not respiratory support or BiPAP education.
D. Respiratory therapist: A respiratory therapist is responsible for providing education on the use of BiPAP, as they are specialists in respiratory equipment and therapy. They ensure that the client knows how to use the machine properly at home.
Correct Answer is A
Explanation
A. Maintain the drainage container below the level of the client's chest. Keeping the drainage container below the level of the client's chest allows gravity to assist in draining fluid or air from the pleural space and prevents backflow into the chest.
B. Add tap water as needed to the suction control chamber: This is incorrect; sterile water should be used, not tap water, to prevent contamination.
C. Clamp the chest tubes if it becomes disconnected: This is not recommended as clamping can create a tension pneumothorax. Instead, the nurse should use a sterile gauze to cover the site and notify the provider.
D. Empty the collection container every shift: The collection container should be emptied as needed, not on a set schedule, to ensure proper function and accurate measurement of drainage.