A client who is experiencing respiratory distress is admitted with respiratory acidosis.

Which pathophysiological process supports the client's respiratory acidosis?

Carbon dioxide is converted in the kidneys for elimination.

Hyperventilation is eliminating carbon dioxide rapidly.

High levels of carbon dioxide have accumulated in the blood.

Blood oxygen levels are stimulating the respiratory rate.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Incorrect. The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than carbon dioxide. They do not significantly convert carbon dioxide for elimination.

Elaboration: While the kidneys help regulate acid-base balance through reabsorption and excretion of bicarbonate and hydrogen ions, their role in carbon dioxide elimination is minimal. They primarily excrete acids like uric acid, phosphoric acid, and lactic acid.

Choice B rationale:

Incorrect. Hyperventilation would decrease carbon dioxide levels, not contribute to respiratory acidosis. Respiratory acidosis is characterized by elevated carbon dioxide levels.

Elaboration: Hyperventilation leads to rapid and excessive breathing, causing a decrease in carbon dioxide levels in the blood. This can result in respiratory alkalosis, not respiratory acidosis.

Choice C rationale:

Correct. Respiratory acidosis is caused by the accumulation of carbon dioxide in the blood. This can happen due to impaired ventilation, such as in conditions like chronic obstructive pulmonary disease (COPD), pneumonia, or respiratory failure.

Elaboration: Carbon dioxide is produced as a byproduct of cellular metabolism. It is normally removed from the body through exhalation. When ventilation is impaired, carbon dioxide cannot be efficiently eliminated, leading to its buildup in the blood. This excess carbon dioxide reacts with water to form carbonic acid, lowering blood pH and causing respiratory acidosis.

Choice D rationale:

Incorrect. Low blood oxygen levels (hypoxemia) can stimulate the respiratory rate, but this would not directly cause respiratory acidosis. It might lead to hyperventilation, which could potentially cause respiratory alkalosis.

Elaboration: The body's respiratory center in the brainstem regulates breathing based on blood oxygen and carbon dioxide levels. Hypoxemia triggers a compensatory increase in respiratory rate to enhance oxygen intake. However, this response does not directly contribute to respiratory acidosis.

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Correct Answer is C

Explanation

Choice A rationale:

Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.

Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.

Choice B rationale:

While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.

The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.

Choice C rationale:

Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.

This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.

The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.

This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.

Choice D rationale:

Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.

A. Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts. B. Reports of chronic constipation and serum gastrin levels. C. Severity of nausea and vomiting and serum amylase results. D. Presence of bowel sounds and degree of abdominal pain.

Correct Answer is C

Explanation

Rationale for Choice A:

Serum Helicobacter pylori (H. pylori) antibody results are not directly relevant to the diagnosis or management of acute pancreatitis. While H. pylori infection can cause gastritis and peptic ulcers, it is not a common cause of pancreatitis.

Urine output amounts are important to monitor in patients with pancreatitis to assess for dehydration and kidney function. However, they are not as specific to the diagnosis of pancreatitis as other findings.

Rationale for Choice B:

Reports of chronic constipation are not typically associated with acute pancreatitis.

Serum gastrin levels are used to diagnose conditions such as Zollinger-Ellison syndrome, which is characterized by excessive acid production in the stomach. They are not relevant to the diagnosis of pancreatitis.

Rationale for Choice C:

Severity of nausea and vomiting are key symptoms of pancreatitis. The severity of these symptoms can help to gauge the severity of the pancreatitis and guide treatment decisions.

Serum amylase results are a highly sensitive and specific marker for pancreatitis. Elevated levels of amylase in the blood strongly suggest the presence of pancreatitis.

Rationale for Choice D:

Presence of bowel sounds can be variable in patients with pancreatitis and are not always reliable indicators of the severity of the condition.

Degree of abdominal pain is a subjective symptom that can be difficult to assess accurately. While it is an important symptom of pancreatitis, it is not as objective as other findings such as serum amylase levels.

Therefore, the most valuable information to report to the healthcare provider in this case is the severity of nausea and vomiting and serum amylase results.

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A client who is experiencing respiratory distress is admitted with respiratory acidosis.Which pathophysiological process supports the client's respiratory acidosis?

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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A client who is experiencing respiratory distress is admitted with respiratory acidosis.

Which pathophysiological process supports the client's respiratory acidosis?