The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur?
The client's sodium and chloride levels will rise.
The client's arterial blood gas results will reflect acidosis.
The client will lose consciousness.
The client will complain of facial numbness and tingling.
The Correct Answer is B
A. The client's sodium and chloride levels will rise: CO₂ retention affects acid-base balance more directly than it affects electrolyte concentrations like sodium or chloride. Changes in these levels may occur in severe or chronic cases, but they are not the initial response.
B. The client's arterial blood gas results will reflect acidosis: When CO₂ accumulates in the blood due to hypoventilation, it forms carbonic acid, lowering blood pH. This results in respiratory acidosis, which is typically the earliest and most direct physiological response to CO₂ retention.
C. The client will lose consciousness: Loss of consciousness may occur if CO₂ levels rise dramatically and go uncorrected. However, this is a late sign of severe respiratory failure, not the initial or most sensitive indicator.
D. The client will complain of facial numbness and tingling: These symptoms are more characteristic of respiratory alkalosis, often due to hyperventilation, not CO₂ retention. In respiratory acidosis, symptoms are more likely to include drowsiness, confusion, or headache.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature of 101.8°F:A temperature above 100.4°F indicates continued fever and inflammation, suggesting the infection is still active. A persistent fever does not reflect clinical improvement and may warrant further assessment or intervention.
B. WBC count of 17,500/mm³:An elevated white blood cell count suggests ongoing infection or inflammation. Normal WBC counts typically range from 4,000 to 11,000/mm³. This elevated value indicates the body is still actively fighting an illness.
C. Respiratory rate of 28:A normal adult respiratory rate is 12–20 breaths per minute. A rate of 28 suggests the patient is still experiencing respiratory distress, possibly due to hypoxia or infection, which does not indicate improvement.
D. Oxygen saturation of 94% on 2L/nasal cannula:An SpO₂ of 94% on low-flow oxygen shows that the patient is maintaining adequate oxygenation with minimal support. This indicates an improving respiratory status and better gas exchange, reflecting clinical progress.
Correct Answer is ["42"]
Explanation
Calculation:
Total volume to be infused = 250 mL.
- Identify the infusion time and convert it to minutes.
Infusion time = 1.5 hours
Infusion time in minutes = 1.5 hours × 60 minutes/hour
= 90 minutes..
Drop factor = 15 gtt/mL.
- Calculate the flow rate in milliliters per minute (mL/minute).
Flow rate (mL/minute) = Total volume (mL) / Infusion time (minutes)
= 250 mL / 90 minutes
= 2.7777 mL/minute.
- Calculate the flow rate in drops per minute (gtt/minute).
Flow rate (gtt/minute) = Flow rate (mL/minute) × Drop factor (gtt/mL)
= 2.7777 mL/minute × 15 gtt/mL
= 41.6666 gtt/minute.
- Round the answer to the nearest whole number.
= 42 gtt/minute.
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