The nurse is caring for a client who overdosed on acetylsalicylic ...

[WWatsford]

The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse expects to note which of the following findings associated with an anticipated acid-base disturbance?
 
  1. Disorientation and dyspnea
  2. Drowsiness, headache, and tachypnea
  3. Tachypnea, dizziness, and paresthesias
  4. Decreased respiratory rate and depth, cardiac irregularities

Question 2

A nurse prepares to teach a patient how to perform in-home self-catheterization. The patient asks, Will you be sending a crate of sterile gloves home with me? The best response by the nurse is:
 
  1. The hospital usually provides a 2-week supply of materials.
  2. The social worker can help you order supplies for delivery.
  3. What type of insurance do you have?
  4. You will not need sterile gloves to do this at home.

[amy.lauersdorf90]

Answer to Question 1

2

Rationale: The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. However, by 24 hours postoverdose, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (decreased respiratory rate and depth, cardiac irregularities) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. Disorientation and dyspnea and tachypnea, dizziness, and paresthesias indicate res-piratory acidosis and alkalosis, respectively.

Answer to Question 2

ANS: 4

[WWatsford]

TYSM

[sultana.d]

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