A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should anticipate to assess which signs and symptoms to indicate respiratory acidosis?

Bradypnea, dizziness, and paresthesia

Bradycardia and hyperactivity

Headache, restlessness and confusion.

Irritability and seizures

Answer and Explanation

The Correct Answer is C

A. Bradypnea, dizziness, and paresthesia: Bradypnea is associated with CO₂ retention, but paresthesia (tingling sensations) is more common in alkalosis due to calcium shifts.

B. Bradycardia and hyperactivity: Bradycardia can occur in severe acidosis, but hyperactivity is not a typical sign.

C. Headache, restlessness, and confusion: Respiratory acidosis occurs when CO₂ retention leads to cerebral vasodilation, increasing intracranial pressure and causing headache, restlessness, and confusion.

D. Irritability and seizures: Seizures are more common in severe alkalosis due to neuronal hyperexcitability.

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Correct Answer is A

Explanation

A. Hypokalemia: Tap water enemas can cause excessive fluid shifts, leading to potassium loss via stool and dilutional effects. Multiple enemas can result in hypokalemia (low K⁺), which may cause muscle weakness and cardiac arrhythmias.

B. Hypocalcemia: Tap water enemas do not significantly affect calcium levels.

C. Hypernatremia: Tap water is hypotonic, leading to fluid absorption rather than sodium excess.

D. Hyperphosphatemia: Enemas can cause hypophosphatemia rather than excess phosphate levels.

A. Prepare the client for dialysis. B. Start an IV and run normal saline at 50m/hour. C. Repeat the electrolyte values later in the day D. Monitor urine output

Correct Answer is A

Explanation

A. Prepare the client for dialysis: A potassium level of 8.3 mEq/L is critically high (normal range: 3.5–5.3 mEq/L), putting the client at immediate risk for life-threatening cardiac arrhythmias (e.g., ventricular fibrillation). Emergency dialysis is needed to remove excess potassium if other interventions (e.g., insulin, calcium gluconate) fail.

B. Start an IV and run normal saline at 50mL/hour: Fluid administration alone does not lower potassium quickly enough in a life-threatening situation.

C. Repeat the electrolyte values later in the day: Delaying treatment would increase the risk of cardiac arrest.

D. Monitor urine output: Although important, monitoring alone does not treat the emergency. Clients with acute renal failure often have little to no urine output.

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A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should anticipate to assess which signs and symptoms to indicate respiratory acidosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What type of electrolyte imbalance would most likely occur following the administration of three tap water enemas?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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