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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Oliguria: Reduced urine output (oliguria) can indicate acute rejection due to decreased renal function. Other signs include fever, hypertension, graft tenderness, and swelling.
B. Temperature 36.1° C (97.0° F): Rejection often causes fever, not a low temperature.
C. Weight loss: Weight gain (fluid retention) is more common with rejection.
D. Insomnia: Insomnia is not a direct sign of rejection.
Correct Answer is B
Explanation
A. Assess the fistula with a large bore needle: Large bore needles are used during dialysis sessions, not for routine assessment. Inappropriate needling can damage the fistula.
B. Auscultate the fistula site for a bruit: A functional AV fistula should have a palpable thrill (vibration) and an audible bruit (whooshing sound) when auscultated with a stethoscope. These findings confirm adequate blood flow and patency.
C. Measure the blood pressure in the affected arm: Blood pressure measurements should never be taken on the fistula arm to prevent compression and potential fistula failure.
D. Assess the rate and quality of the radial pulse on the affected arm: The radial pulse does not accurately assess AV fistula patency; the focus should be on the thrill and bruit.
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