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?

Choice A rationale

Negligence is the failure to exercise the care that a reasonably prudent person would exercise in similar circumstances. While administering the wrong medication is a breach of duty, legal charges of negligence might not fully capture the severity of a serious untoward reaction resulting from a medication error by a professional.

Choice B rationale

Malpractice is a specific type of negligence committed by a professional, such as a nurse, in the performance of their professional duties. Administering the wrong medication, leading to a serious adverse reaction, falls under the scope of professional nursing practice and can be considered a breach of the professional standard of care, thus potentially leading to charges of malpractice.

Choice C rationale

Assault is an intentional act that creates a reasonable apprehension of immediate harmful or offensive contact. Administering medication, even the wrong one, is usually not intended to cause apprehension of harm in the way assault is legally defined.

Choice D rationale

Battery is the intentional touching of another person without consent. While administering the wrong medication involves touching without consent, the more appropriate legal charge in a professional healthcare setting where harm results from a breach of duty is typically malpractice. .

Choice A rationale

Fluid Volume Excess occurs in congestive heart failure due to the heart's inability to pump blood effectively, leading to increased hydrostatic pressure in the capillaries. This pressure forces fluid into the interstitial spaces, causing edema. Orthopnea, or difficulty breathing while lying flat, results from the redistribution of this excess fluid into the pulmonary circulation when supine, increasing pressure in the lungs.

Choice B rationale

Fluid Volume Deficit is characterized by dehydration, typically presenting with symptoms like poor skin turgor, dry mucous membranes, and concentrated urine. Confusion in dehydration is due to reduced cerebral perfusion. These signs and symptoms are contrary to the findings of edema and orthopnea, which indicate fluid overload, not deficit.

Choice C rationale

Impaired Gas Exchange is a potential complication of congestive heart failure due to fluid accumulation in the lungs (pulmonary edema). While orthopnea is a symptom of this, the primary evidence for impaired gas exchange would be abnormal blood gas values (e.g., low PaO2, high PaCO2) and clinical signs of hypoxemia, not just orthopnea and shortness of breath alone.

Choice D rationale

Risk for Falls is a relevant concern for an elderly client with confusion, as altered mental status can impair judgment and coordination, increasing the likelihood of falls. However, this diagnosis does not directly address the primary physiological problem of fluid overload evidenced by edema and orthopnea in the context of heart failure.