The nurse is caring for a patient who presents in the emergency room with respiratory acidosis.
After assessing the patient, which of the patient's findings is the probable cause of respiratory acidosis?
Hypokalemia.
High Fever.
Extreme Anxiety.
Sedative Overdose.
The Correct Answer is D
Choice A rationale
Hypokalemia, a deficiency of potassium in the blood (normal range: 3.5-5.0 mEq/L), typically leads to metabolic alkalosis due to intracellular hydrogen ion shifts. While respiratory and metabolic acid-base balances are interconnected, hypokalemia itself does not directly cause the retention of carbon dioxide, which is the hallmark of respiratory acidosis.
Choice B rationale
A high fever increases the metabolic rate, leading to increased oxygen consumption and carbon dioxide production. However, the body usually compensates for this by increasing the respiratory rate to expel the excess carbon dioxide. Therefore, while fever affects gas exchange, it is more likely to cause respiratory alkalosis due to hyperventilation, not acidosis.
Choice C rationale
Extreme anxiety can lead to hyperventilation, causing an excessive exhalation of carbon dioxide and a subsequent decrease in the partial pressure of carbon dioxide in the arterial blood (PaCO2). This results in respiratory alkalosis, not respiratory acidosis, where the PaCO2 is elevated (normal range: 35-45 mmHg).
Choice D rationale
Sedative overdose depresses the central nervous system, including the respiratory center in the brainstem. This depression leads to a decrease in both the rate and depth of breathing (hypoventilation). Inadequate ventilation causes the retention of carbon dioxide, leading to an increase in PaCO2 and a decrease in blood pH (normal range: 7.35-7.45), resulting in respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Dividing time evenly among patients reflects the professional value of justice, ensuring fair allocation of nursing resources based on patient needs rather than strict equality of time. Justice in nursing involves impartiality and equitable treatment.
Choice B rationale
Demonstrating care and concern for a patient's culture and beliefs aligns with the professional value of respect for autonomy and human dignity. It involves acknowledging and valuing the patient's individuality and their right to self-determination in healthcare decisions.
Choice C rationale
Encouraging the patient to make decisions about food selection promotes patient autonomy, allowing them to exercise their right to make choices about their care. This respects their preferences and empowers them in their healthcare journey.
Choice D rationale
Performing patient assessment and recording findings accurately exemplifies integrity, which involves honesty, truthfulness, and adherence to ethical principles. Accurate documentation provides an honest representation of the patient's condition and the care provided, crucial for safe and effective nursing practice.
Correct Answer is D
Explanation
Choice A rationale
Performing nursing tasks quickly might compromise the quality and thoroughness of care. Unconscious patients still require careful and meticulous attention to their needs, and rushing could lead to errors or omissions in care.
Choice B rationale
Discouraging family members from touching an unconscious patient can be detrimental to the patient's well-being. Even in an unconscious state, patients may benefit from the familiar touch and presence of loved ones, which can provide comfort and potentially aid in sensory processing.
Choice C rationale
Turning the television to a loud volume is unlikely to be beneficial for an unconscious patient and could be overstimulating or even distressing. Sensory stimulation for unconscious patients should be carefully considered and usually involves gentle, controlled inputs rather than loud, indiscriminate noise.
Choice D rationale
Explaining procedures to an unconscious patient in a normal tone of voice is an appropriate action. Although the patient may not consciously understand, they may still have some level of auditory processing. Speaking calmly and explaining actions can also provide a sense of respect and dignity for the patient. .
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