A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Circumoral numbness and tingling

Muscle flaccidity

Decreased level of consciousness

Cool, clammy skin

Answer and Explanation

The Correct Answer is C

Acute respiratory acidosis occurs when there is inadequate excretion of carbon dioxide due to respiratory dysfunction, leading to an increase in carbon dioxide levels (hypercapnia) and subsequent acidosis (decrease in pH).

Manifestations of acute respiratory acidosis include:

A. Circumoral numbness and tingling - This is associated with respiratory alkalosis, not acidosis. B. Muscle flaccidity - This is more commonly seen in hyperkalemia or conditions affecting neuromuscular transmission. C. Decreased level of consciousness - This is a key manifestation of acute respiratory acidosis due to the effects of hypercapnia on the central nervous system. D. Cool, clammy skin - This is not typically associated with acute respiratory acidosis; instead, it might be seen in shock or hypoperfusion states.

Therefore, the nurse should expect to find a decreased level of consciousness in a client experiencing acute respiratory acidosis.

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Correct Answer is D

Explanation

(A) Glasgow coma scale result:
The Glasgow Coma Scale (GCS) result is important and would be included in the "Assessment" segment of SBAR, as it provides current data on the client's level of consciousness and neurological status.

(B) Intracranial pressure readings:
Intracranial pressure (ICP) readings are crucial for monitoring the client's condition but would be more appropriately included in the "Assessment" or "Background" segments, as they provide ongoing data relevant to the client's current health status and trends.

(C) Medication during the next shift:
Medication information, especially about what needs to be administered during the next shift, would fall under the "Recommendation" segment. This is where the outgoing nurse would specify what needs to be done next for the client's care.

(D) History of the injury:
The history of the injury is part of the "Situation" segment in SBAR reporting. This includes a brief description of why the client is being reported on, providing context for their current condition. For a client with a traumatic brain injury, this would involve a summary of how the injury occurred, which sets the stage for understanding the client's current status and care needs.

Correct Answer is ["2"]

Explanation

Let's calculate how many tablets the nurse should administer:

Dosage prescribed: The doctor prescribed digoxin 0.25 mg.

Tablet strength: Each available tablet contains 0.125 mg of digoxin.

To find out how many tablets are needed, we can divide the prescribed dosage by the amount of digoxin per tablet:

Number of tablets = Prescribed dosage / Amount of digoxin per tablet

Number of tablets = 0.25 mg / 0.125 mg/tablet

Since we might get a decimal result due to the division, we need to round to the nearest whole number of tablets the nurse can administer for safety reasons.

In this case, dividing 0.25 mg by 0.125 mg/tablet gives us 2.

Therefore, rounding up to the nearest whole number of tablets, the nurse should administer 2 tablets.

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A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Correct Answer is D

Explanation

A nurse is preparing to administer digoxin 0.25 mg PO to a client. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer to the client? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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