A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Circumoral numbness and tingling

Muscle flaccidity

Decreased level of consciousness

Cool, clammy skin

Answer and Explanation

The Correct Answer is C

Acute respiratory acidosis occurs when there is inadequate excretion of carbon dioxide due to respiratory dysfunction, leading to an increase in carbon dioxide levels (hypercapnia) and subsequent acidosis (decrease in pH).

Manifestations of acute respiratory acidosis include:

A. Circumoral numbness and tingling - This is associated with respiratory alkalosis, not acidosis. B. Muscle flaccidity - This is more commonly seen in hyperkalemia or conditions affecting neuromuscular transmission. C. Decreased level of consciousness - This is a key manifestation of acute respiratory acidosis due to the effects of hypercapnia on the central nervous system. D. Cool, clammy skin - This is not typically associated with acute respiratory acidosis; instead, it might be seen in shock or hypoperfusion states.

Therefore, the nurse should expect to find a decreased level of consciousness in a client experiencing acute respiratory acidosis.

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Correct Answer is B

Explanation

B. Aspirin:
Aspirin is the priority medication to administer first. It is crucial for preventing further clot formation in the coronary arteries, as it inhibits platelet aggregation. Administering aspirin early in the treatment of a suspected MI helps reduce the size of the infarction and limits further damage to the heart muscle. Aspirin should be given as soon as a myocardial infarction is suspected, unless contraindicated.

A. Insert the IV catheter. B. Obtain a blood sample. C. Attach the leads for a 12-lead ECG. D. Initiate oxygen therapy.

Correct Answer is D

Explanation

A. Insert the IV catheter:

Inserting an IV catheter is necessary to administer IV fluids and medications. However, it is not the most immediate need. The priority is to address the client's oxygenation status first to stabilize them before proceeding with other interventions.

B. Obtain a blood sample:

Obtaining a blood sample for cardiac enzyme levels is important to diagnose a myocardial infarction. Nevertheless, this step should be taken after ensuring the client is receiving adequate oxygen, as hypoxia needs to be addressed immediately.

C. Attach the leads for a 12-lead ECG:

Attaching the leads for a 12-lead ECG is crucial for diagnosing the client's cardiac condition. However, it should be done after initiating oxygen therapy, as improving the client's oxygenation status is more urgent and can help stabilize the client for further diagnostic procedures.

D. Initiate oxygen therapy:

Initiating oxygen therapy is the most critical first action. The client is experiencing severe chest pain, shortness of breath, and signs of cyanosis, indicating that their oxygen levels are insufficient. Providing oxygen at 4 L/min via nasal cannula will help alleviate hypoxia, improve the client's condition, and provide time for further diagnostic and therapeutic interventions.

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A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is D

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