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. Provide prophylactic antibiotics for clients who have been exposed to influenza: Antibiotics are not effective against viral infections like influenza. Antiviral medications may be used for prophylaxis in exposed individuals.
B. Assign health care personnel to non-direct care activities for 24 hr after developing influenza symptoms: Healthcare personnel should not provide care while symptomatic. The recommended restriction period is typically longer than 24 hours.
C. Place restrictions on visitation. During an influenza outbreak, limiting visitation can reduce the spread of infection, especially in vulnerable populations like those in long-term care facilities.
D. Implement airborne precautions for clients who have influenza: Influenza is spread through droplets, not airborne particles. Droplet precautions are appropriate.
Correct Answer is A
Explanation
A. Encourage the client to cough and deep breathe. Encouraging the client to cough and deep breathe promotes the clearance of secretions and improves lung expansion, which is critical in treating pneumonia.
B. Encourage the client to increase oral fluids: This helps to thin secretions, but encouraging deep breathing and coughing is more immediate and effective for clearing secretions.
C. Provide chest percussion on the client: Chest percussion helps mobilize secretions but is not the priority before ensuring the client is actively coughing and deep breathing.
D. Obtain the client’s temperature: While monitoring vital signs is important, clearing secretions is the priority for improving respiratory status in pneumonia.