A nurse is collecting data on a client who has respiratory alkalosis. Which of the following findings should the nurse expect?
Abdominal pain
Hyperventilation
constipation
Dry skin
The Correct Answer is B
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).
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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.
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.