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. “They’ll protect your legs and heels from skin breakdown.”: While antiembolism stockings can provide some degree of protection against skin breakdown due to their snug fit, this is not their primary purpose. Their main function is to improve circulation and prevent blood clots, not to protect the skin.

B. “They’ll make it easier for you to do leg exercises after your surgery.”: Antiembolism stockings do not directly facilitate leg exercises. While they can help improve circulation which might indirectly aid in recovery, their primary purpose is to prevent the formation of blood clots in the lower extremities.

C. “They’ll improve your circulation to keep blood from pooling in your legs.”: This is correct. Antiembolism stockings, also known as compression stockings, are designed to apply pressure to your lower legs, helping to maintain blood flow and reduce discomfort and swelling. They can help prevent deep vein thrombosis (DVT), a type of blood clot that’s most common in the deep veins of your legs.

D. “They’ll help keep you warm immediately after your surgery.”: While antiembolism stockings might provide some warmth due to their material, this is not their primary function. Their main purpose is to improve circulation in the legs and prevent blood clots.

A. Obtain the client's consent. B. Describe the consequences of forgoing treatment. C. Witness the client's signature. D. Explain the risks and benefits of the procedure.

Correct Answer is C

Explanation

A. Obtain the client’s consent: It is not the nurse’s responsibility to obtain the client’s consent for a procedure. This responsibility lies with the healthcare provider performing the procedure.

B. Describe the consequences of forgoing treatment: While it’s important for the client to understand the consequences of not undergoing the procedure, it is the healthcare provider’s responsibility to explain these consequences, not the nurses.

C. Witness the client’s signature: This is correct. The nurse’s role in the informed consent process is to witness the client’s signature on the consent form and to verify that the client is consenting voluntarily and appears to be competent to do so.

D. Explain the risks and benefits of the procedure: While the nurse can reinforce information, it is the healthcare provider’s responsibility to explain the risks and benefits of the procedure. The nurse should ensure that the client understands the information provided by the healthcare provider

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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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