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 C

Explanation

A. Verify that the client's valuables have been secured:

While securing the client's valuables is important for their safety and security during hospitalization, it does not directly address the prevention of postoperative complications.
B. Discuss a discharge date with the client:

Discussing a discharge date is part of discharge planning but does not directly address the prevention of postoperative complications.
C. Inform the client about the need for sequential compression devices:

Sequential compression devices (SCDs) are mechanical devices that help prevent venous stasis and deep vein thrombosis (DVT) by promoting circulation in the lower extremities. They are commonly used in surgical patients to reduce the risk of blood clots and related complications.
D. Review the facility's visitation policy with the client and family:

Reviewing the facility's visitation policy is important for ensuring that the client and family understand the rules and regulations regarding visitors. While visitor policies contribute to the overall well-being of the client during their hospital stay, they do not directly address the prevention of postoperative complications like the use of sequential compression devices does.

A. Provide educational material written at an eighth-grade reading level B. Ensure privacy for the client. C. Start with the least important information. D. Dim the lights in the client's room.

Correct Answer is A

Explanation

A. Provide educational material written at an eighth-grade reading level: This is correct. Health education materials should be written at a level that is easily understandable by the majority of patients. An eighth-grade reading level is often recommended to ensure that the information is accessible to a wide range of patients.

B. Ensure privacy for the client: This is also correct. Privacy is a fundamental right of all patients and is particularly important when discussing sensitive topics such as preoperative care. Ensuring privacy can help the patient feel more comfortable and facilitate open communication.

C. Start with the least important information: This is not recommended. When providing education, it’s generally best to start with the most important information. Patients may be anxious or overwhelmed, and they may not remember everything that is discussed. By starting with the most important information, you increase the chances that the patient will remember and understand the key points.

D. Dim the lights in the client’s room: While creating a comfortable environment is important, dimming the lights is not specifically related to preoperative teaching. The focus should be on providing clear, understandable information and addressing the patient’s questions and concerns.

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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?

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