A nurse is assessing a client who has respiratory failure. Which of the following manifestations should the nurse identify as indicative of severe hypercapnia?

Cyanosis

Arrhythmias

Asterixis

Tachycardia

Answer and Explanation

The Correct Answer is C

A. Cyanosis: Cyanosis is a late sign of hypoxemia, not specifically hypercapnia. It indicates poor oxygenation of tissues but does not directly reflect elevated carbon dioxide levels in the blood.
B. Arrhythmias: Arrhythmias may occur in respiratory failure due to hypoxemia or acid-base disturbances. However, they are not the most specific indicator of severe hypercapnia and can result from a range of metabolic or cardiac causes.
C. Asterixis: Asterixis, or "flapping tremor," is a neurologic manifestation of severe hypercapnia and altered mental status. It results from elevated CO₂ levels affecting brain function and is often seen in CO₂ narcosis or advanced respiratory failure.
D. Tachycardia: Tachycardia is a common compensatory response to hypoxia or hypercapnia, but it is nonspecific. It can be seen in many conditions and is not a definitive sign of severe carbon dioxide retention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ability to target and destroy CD4 lymphocytes: HIV targets and destroys CD4 lymphocytes, which are a key component of the immune system. This destruction weakens the immune system, making the individual more susceptible to opportunistic infections. This is a central feature of HIV's pathogenesis.
B. Conversion of the virus's RNA into DNA: The conversion of HIV's RNA into DNA occurs during replication, but this alone does not cause opportunistic infections. It is the destruction of CD4 cells that leads to the immune suppression and susceptibility to infections.
C. Having reverse transcriptase enzyme: Reverse transcriptase is an enzyme that helps HIV replicate its RNA into DNA. While essential for HIV replication, the presence of reverse transcriptase does not directly cause opportunistic infections; it is the result of the viral replication that weakens the immune system.
D. Containing only a single strand of genetic material: HIV contains single-stranded RNA as its genetic material. While this is true, the key factor in causing opportunistic infections is the virus’s ability to destroy CD4 cells, which weakens the immune system.

A. Deep vein thrombosis B. Myocardial infarction C. Pulmonary embolus D. Bacterial translocation

Correct Answer is D

Explanation

A. Deep vein thrombosis (DVT): Although clients with increased intracranial pressure may be at risk for DVT, this is not the primary concern in the first 24-48 hours. Early enteral nutrition helps prevent gastrointestinal complications, such as bacterial translocation, which can be more immediate and serious.
B. Myocardial infarction: Myocardial infarction is unrelated to the timing of enteral nutrition in clients with increased intracranial pressure. The priority here is to address risks related to the gut and the immune system.
C. Pulmonary embolus: A pulmonary embolus is a serious condition, but is not the most direct consequence of delayed enteral nutrition. While immobility and other factors might increase the risk of embolism, bacterial translocation is the immediate concern.
D. Bacterial translocation: Early enteral nutrition is crucial for maintaining gut integrity and preventing bacterial translocation, which occurs when bacteria from the gut leak into the bloodstream. This can lead to systemic infections and sepsis, which are life-threatening complications in critically ill clients.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who has respiratory failure. Which of the following manifestations should the nurse identify as indicative of severe hypercapnia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client who has HIV about the infection process. Which of the following features of the virus should the nurse explain can result in opportunistic infection?

Correct Answer is A

Explanation

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Correct Answer is D

Explanation

A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?

A nurse is providing care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following physiological alterations is consistent with a diagnosis of SIADH?

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

A nurse is caring for a client who was diagnosed with type 2 diabetes mellitus 2 years ago. The client reports following the recommended diet and exercising four times per week. Which of the following findings indicates that the client's beta cells are restoring normal function?

A nurse is reinforcing teaching to a group of high school students about how penetrating traumatic brain injuries cause damage to the brain. Which of the following statements should the nurse include in the teaching?

A nurse is caring for four clients on the urology unit. Which of the following clients should the nurse plan to teach about kidney stone prevention?