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 A
Explanation
Choice A rationale
Emptying a Foley catheter bag and reporting the urine volume is a routine task that does not require complex assessment or clinical judgment. Unlicensed care providers are typically trained in this procedure and can accurately measure and report the output to the nurse.
Choice B rationale
Helping a first-time mother achieve a good latch during breastfeeding requires specialized knowledge and assessment skills to ensure proper positioning and infant feeding. This task involves teaching and evaluating, which falls within the scope of nursing practice and should not be delegated to an unlicensed care provider.
Choice C rationale
Assessing the size and quantity of blood clots in a postpartum client's bedpan requires clinical judgment to determine if the findings are within normal limits or indicative of a potential complication. This assessment should be performed by a registered nurse who can interpret the findings in the context of the client's overall condition.
Choice D rationale
Administering medication, including anti-inflammatory drugs, is a nursing responsibility that requires knowledge of pharmacology, potential side effects, and client assessment. Medication administration should not be delegated to unlicensed care providers. .
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Moderate consumption of red wine has been associated with potential cardiovascular benefits, primarily attributed to the presence of antioxidants like resveratrol. Resveratrol may help prevent damage to blood vessels, reduce low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol), and prevent blood clots. However, these potential benefits must be balanced against the risks associated with alcohol consumption.
Choice B rationale
Generally, three glasses of red wine would be considered beyond moderate alcohol consumption for most individuals. Moderate drinking is typically defined as up to one drink per day for women and up to two drinks per day for men. Three glasses could lead to significant impairment, increased risk of accidents, and potential long-term health consequences associated with excessive alcohol intake.
Choice C rationale
Individuals with liver disease should generally avoid alcohol consumption altogether. The liver is the primary organ responsible for metabolizing alcohol, and liver disease impairs this function. Consuming alcohol can further damage the liver, exacerbate existing conditions, and lead to serious complications.
Choice D rationale
Alcohol is a diuretic, meaning it increases urine production. This diuretic effect can lead to dehydration if fluid intake does not adequately compensate for the increased fluid loss through urination. Therefore, consuming three glasses of red wine, without sufficient water intake, can contribute to dehydration.
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