The nurse is admitting a client with COPD and respiratory acidosis. Which assessment finding would the nurse anticipate for this client?

Decreasing level of consciousness

Bradycardia

Fever

ABG: Ph 7.31 (7.35-7.45), PaCO2 42 mmHg (35-45mmHg), HCO3 19 mEq/L (22-26 mEq/L)

Answer and Explanation

The Correct Answer is D

Decreasing level of consciousness: This assessment finding is consistent with respiratory acidosis, especially if it is severe. In respiratory acidosis, carbon dioxide (CO2) levels in the blood increase, leading to respiratory depression and potential alterations in consciousness due to hypercapnia. Therefore, a decreasing level of consciousness is a possible finding in a client with respiratory acidosis.

b. Bradycardia: Bradycardia is not typically associated with respiratory acidosis. In fact, it is more commonly associated with respiratory alkalosis, where hyperventilation can lead to decreased CO2 levels and subsequent compensatory metabolic alkalosis.

c. Fever: Fever is not a direct consequence of respiratory acidosis. It may occur in response to an underlying infection or inflammation, which could exacerbate respiratory symptoms in a client with COPD. However, it is not a specific finding associated with respiratory acidosis itself.

d. ABG: pH 7.31, PaCO2 42 mmHg, HCO3 19 mEq/L: This ABG result confirms respiratory acidosis. The pH is below the normal range (acidosis), the PaCO2 is elevated (indicating respiratory acidosis), and the HCO3 is decreased (indicating compensation through renal mechanisms). This ABG finding supports the diagnosis of respiratory acidosis in a client with COPD.

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Correct Answer is ["A","B","C","E"]

Explanation

a. Abdominal distension: Abdominal distension can occur in cases of severe digoxin toxicity due to its effects on gastrointestinal motility. Digoxin toxicity can lead to nausea, vomiting, and abdominal discomfort, which can contribute to abdominal distension. Therefore, abdominal distension is consistent with digoxin toxicity.

b. Digoxin level 4.1 ng/ml (0.8-2.0ng/ml): Digoxin levels above the therapeutic range (0.8-2.0 ng/ml) indicate digoxin toxicity. A level of 4.1 ng/ml is significantly higher than the therapeutic range, confirming digoxin toxicity.

c. Blurry vision: Blurry vision is a common symptom of digoxin toxicity. Visual disturbances, such as yellow or green halos around lights or changes in color vision, can occur due to digoxin's effects on the optic nerve. Therefore, blurry vision is consistent with digoxin toxicity.

d. Increased platelet level: Digoxin toxicity typically does not cause an increase in platelet levels. Instead, it can lead to thrombocytopenia (a decrease in platelet levels) due to its effects on bone marrow function. Therefore, increased platelet levels are not consistent with digoxin toxicity.

e. Arrhythmia: Digoxin toxicity can cause various cardiac arrhythmias, including atrial tachycardia, atrioventricular block, and ventricular tachycardia. Therefore, experiencing arrhythmias is consistent with digoxin toxicity.

A. Check current WBC count B. Assess for hypertension C. Auscultate heart sounds D. Measure blood glucose

Correct Answer is C

Explanation

a. Check current WBC count: While an elevated white blood cell (WBC) count may indicate inflammation, it is not specific to the assessment of cardiac tamponade. WBC count may be elevated in pericarditis due to the inflammatory process, but it does not directly assess for the potential complication of cardiac tamponade.

b. Assess for hypertension: Hypertension is not typically associated with cardiac tamponade. Instead, cardiac tamponade is characterized by hemodynamic compromise, which may manifest as hypotension rather than hypertension. While assessing blood pressure is important in overall cardiovascular assessment, it is not specific to detecting cardiac tamponade.

c. Auscultate heart sounds: Auscultating heart sounds, specifically for the presence of muffled heart sounds (reduced intensity of heart sounds) and distant heart sounds, is a key assessment for detecting cardiac tamponade, a potential complication of pericarditis. Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing cardiac filling. This can lead to hemodynamic compromise and potentially life-threatening consequences. Muffled or distant heart sounds are classic signs of cardiac tamponade and indicate the need for immediate intervention.

d. Measure blood glucose: Blood glucose measurement is not directly related to the assessment of cardiac tamponade. While monitoring blood glucose levels may be important in clients with diabetes or those at risk of hyperglycemia, it does not provide information specific to the detection of cardiac tamponade.

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The nurse is admitting a client with COPD and respiratory acidosis. Which assessment finding would the nurse anticipate for this client?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with digoxin toxicity. Which findings are consistent with this diagnosis? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is planning care for a client with pericarditis. Which intervention assesses for the potential complication of cardiac tamponade?

Correct Answer is C

Explanation

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