The nurse is reviewing the client's following arterial blood gases: pH 7.33, PaCo2 47, HCO3 24. Which manifestation would the nurse expect the client to be experiencing with this imbalance?
Confusion
Kussmaul's Respirations
Seizures
Paresthesia in the extremities
The Correct Answer is A
A. Confusion: Respiratory acidosis (low pH + high PaCO2) leads to decreased oxygenation of brain tissues, causing confusion, drowsiness, and lethargy.
B. Kussmaul's Respirations: Seen in metabolic acidosis, not respiratory acidosis.
C. Seizures: Seizures are more common with alkalosis (high pH) due to neuronal excitability.
D. Paresthesia in the Extremities: More common in respiratory alkalosis due to calcium shifts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assess the fistula with a large bore needle: Large bore needles are used during dialysis sessions, not for routine assessment. Inappropriate needling can damage the fistula.
B. Auscultate the fistula site for a bruit: A functional AV fistula should have a palpable thrill (vibration) and an audible bruit (whooshing sound) when auscultated with a stethoscope. These findings confirm adequate blood flow and patency.
C. Measure the blood pressure in the affected arm: Blood pressure measurements should never be taken on the fistula arm to prevent compression and potential fistula failure.
D. Assess the rate and quality of the radial pulse on the affected arm: The radial pulse does not accurately assess AV fistula patency; the focus should be on the thrill and bruit.
Correct Answer is A
Explanation
A. Cardiac arrest: Cardiac arrest is a complication of severe hypothermia, not a risk factor.
B. Falling through the ice: Major risk factor for accidental hypothermia due to immersion in cold water.
C. Head trauma: Impaired thermoregulation in the brainstem can cause hypothermia.
D. Drug use: Certain drugs (e.g., alcohol, sedatives) impair the body’s ability to regulate temperature, increasing hypothermia risk.
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