A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?
Hyperactive deep tendon reflexes.
Warm, flushed skin.
Widened QRS Complexes.
Bounding peripheral pulses.
The Correct Answer is C
Widened QRS Complexes.
Choice A rationale:
Hyperactive deep tendon reflexes are not typical findings in respiratory acidosis. They are more commonly associated with conditions like hypocalcemia or hypercalcemia.
Choice B rationale:
Warm, flushed skin is not directly related to respiratory acidosis. It is not a typical manifestation of this acid-base imbalance.
Choice C rationale:
Widened QRS complexes on an ECG are characteristic findings in respiratory acidosis. Acidosis can lead to changes in the electrical conduction of the heart, resulting in QRS complex widening.
Choice D rationale:
Bounding peripheral pulses are not directly associated with respiratory acidosis. They may be seen in conditions like hyperthyroidism or anemia but are not specific to respiratory acidosis. Remember, always interpret lab results and clinical findings in the context of the patient's overall condition, medical history, and other relevant factors to provide the best care possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Fluid volume overload is an excess of fluid in the intravascular and/or interstitial spaces. One of the hallmark signs of fluid volume overload is distended neck veins, which indicates increased venous pressure due to the accumulation of fluid. The neck veins become more visible and prominent, especially when the patient is in a semi-Fowler's position.
Choice B rationale:
Poor skin turgor is a sign of dehydration, not fluid volume overload. It is characterized by the skin's inability to return to its normal position after being gently pinched. In fluid volume overload, the skin may become edematous and puffy, but it does not exhibit poor turgor.
Choice C rationale:
Concentrated hemoglobin and hematocrit levels are seen in conditions of dehydration or hemoconcentration, not in fluid volume overload. In fluid volume overload, there is excess fluid, which may lead to dilutional effects, resulting in decreased concentration of blood components.
Choice D rationale:
Decreased urine output is associated with fluid volume deficit (dehydration) rather than fluid volume overload. In fluid volume overload, there is often an increase in urine output as the body tries to eliminate the excess fluid.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.
Choice B rationale:
Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.
Choice C rationale:
Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.
Choice D rationale:
Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.
Choice E rationale:
Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.
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