Related Questions

Correct Answer is A

Explanation

Choice A Reason: This is correct because a client who is short of breath is in immediate danger, as it indicates a possible respiratory compromise or failure. The nurse should assess the client's oxygen saturation, respiratory rate, and lung sounds, and provide oxygen therapy as needed.

Choice B Reason: This is incorrect because a client who received oral pain medication 30 min ago is not in immediate danger, as it indicates that the client's pain has been managed and the medication has had time to take effect.

Choice C Reason: This is incorrect because a client who is scheduled for an abdominal x-ray and is awaiting transport is not in immediate danger, as it indicates that the client's condition is stable and the diagnostic test is not urgent.

Choice D Reason: This is incorrect because a client who has a prescription for discharge is not in immediate danger, as it indicates that the client's condition has improved and the client is ready to leave the hospital.

Correct Answer is D

Explanation

Choice A Reason: This choice is incorrect because warm, flushed skin is not a sign of respiratory acidosis. Warm, flushed skin may indicate fever, infection, inflammation, or allergic reaction, but it does not reflect the acid-base imbalance in the blood.

Choice B Reason: This choice is incorrect because hyperactive deep tendon reflexes are not a sign of respiratory acidosis. Hyperactive deep tendon reflexes may indicate hypocalcemia, hyperthyroidism, or spinal cord injury, but they do not reflect the carbon dioxide level in the blood.

Choice C Reason: This choice is incorrect because bounding peripheral pulses are not a sign of respiratory acidosis. Bounding peripheral pulses may indicate increased cardiac output, anxiety, or hyperthyroidism, but they do not reflect the pH level in the blood.

Choice D Reason: This choice is correct because widened QRS complexes are a sign of respiratory acidosis. QRS complexes are the segments on an electrocardiogram (ECG) that represent the depolarization of the ventricles. A normal QRS complex duration is 0.06 to 0.10 seconds, and a widened QRS complex duration is more than 0.12 seconds. A widened QRS complex may indicate hyperkalemia, which is a common complication of kidney failure and respiratory acidosis. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may cause cardiac arrhythmias, muscle weakness, or paralysis.

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