What causes respiratory acidosis?

Decreased CO2

Overproduction of hydrogen ions

Hyperventilation

Retention of CO2

Answer and Explanation

The Correct Answer is D

A. Decreased CO2: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2), not a decrease. Decreased CO2 would lead to respiratory alkalosis, not acidosis.

B. Overproduction of hydrogen ions: While the overproduction of hydrogen ions can lead to acidosis, this is typically seen in metabolic acidosis, not respiratory acidosis. In respiratory acidosis, the issue is related to CO2 retention, not hydrogen ion production.

C. Hyperventilation: Hyperventilation leads to the exhalation of excessive CO2, which would decrease CO2 levels in the blood. This results in respiratory alkalosis, not acidosis.

D. Retention of CO2: Respiratory acidosis occurs when the lungs are unable to exhale enough CO2, leading to its retention in the blood. This increased CO2 concentration causes a decrease in pH, resulting in respiratory acidosis.

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Correct Answer is ["A","B","D"]

Explanation

A. Never give KCI intramuscularly (IM) or as an IV bolus: Potassium chloride (KCl) should never be administered via IM injection or as an IV bolus. Both methods can cause severe irritation, tissue necrosis, and cardiac complications. Potassium should be given slowly and diluted to prevent these risks.

B. Always dilute potassium chloride in a large amount of IV solution: Potassium chloride must always be diluted when administered IV to prevent vein irritation and reduce the risk of hyperkalemia. It should be given in a large volume of fluid to ensure safe, slow infusion.

C. Never administer more than 40 mEq/L of IV potassium chloride (KCl) per hour: While the general recommendation is to limit the infusion rate to 10-20 mEq/hour for most patients, in certain situations, doses higher than 40 mEq/L per hour might be prescribed under close monitoring depending on the specific clinical situation.

D. Monitor the IV site frequently for early signs of infiltration, as potassium is caustic to the tissues: Potassium chloride is irritating to veins and tissues. If the IV infiltrates (leaks into the surrounding tissue), it can cause significant tissue damage, so frequent monitoring of the IV site is essential.

A. Assess the patients for edema in extremities. B. Ask the patients to record their intake and output. C. Weigh the patients every morning before breakfast. D. Measure the patients' blood pressures every 4 hours.

Correct Answer is C

Explanation

A. Assess the patients for edema in extremities: While assessing for edema can be helpful in heart failure patients, it may not be the most effective method to monitor fluid volume status in patients at risk for dehydration, as edema may not be present in early dehydration.

B. Ask the patients to record their intake and output: Recording intake and output is important for monitoring fluid balance, but it is not as reliable as daily weight measurements. Patients may not be accurate in recording intake and output, especially in acute settings.

C. Weigh the patients every morning before breakfast: Weighing patients at the same time every day provides the most accurate and reliable measure of fluid volume status. A sudden weight gain or loss can indicate fluid retention in heart failure or dehydration, making this the most effective intervention for monitoring fluid status in both conditions.

D. Measure the patients' blood pressures every 4 hours: Blood pressure monitoring can provide some insight into fluid status, but it is not as directly indicative of fluid volume as daily weights. BP changes may not be as sensitive to small fluctuations in fluid volume.

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What causes respiratory acidosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When administering potassium chloride, which of following safety precautions must be observed? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients?

Correct Answer is C

Explanation

The failure of the lungs to adequately eliminate CO2 results in?

The nurse is aware that which of the following results when a decreased concentration of hydrogen ions occurs within body fluids?

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?

A client at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How should the nurse respond?

The physician orders 1000 mL lactated Ringer's to infuse at 125 mL/h for a postoperative patient. Tubing drop factor is 20 gtt/mL. Calculate the flow rate in drops per minute.

A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the client's acid-base balance?

A nurse is collecting data from a client who is dehydrated due to fluid volume deficit. Which of the following findings should the nurse expect?

The nurse is caring for a client with a critically high potassium level (Normal is 3.5-5.0 mEq/L). The client has received sodium polystyrene sulfonate (Kayexalate). The nurse determines the medication's effectiveness if the client's repeat serum potassium level is: