Question

A nurse is assessing a client who is experiencing respiratory acidosis. Which of the following manifestations should the nurse expect to observe?

Answer 1

Correct Answers:

Confusion

Rationale :

♠️ Respiratory acidosis occurs when inadequate ventilation causes retention of carbon dioxide (CO₂).

♠️ Increased PaCO₂ causes the blood pH to decrease below 7.35, producing acidemia.

♠️ Excess CO₂ readily crosses the blood-brain barrier and affects central nervous system function.

♠️ Neurologic manifestations can include headache, confusion, decreased level of consciousness, and drowsiness.

♠️ As respiratory acidosis becomes more severe, the client can develop increasing CNS depression.

♠️ The nurse should closely assess mental status, respiratory pattern, oxygenation, and ABG values.

♠️ Severe CO₂ retention can progress to CO₂ narcosis, respiratory failure, and coma if ventilation is not improved.

♠️ Confusion is therefore an expected manifestation of respiratory acidosis caused by the neurologic effects of hypercapnia.

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Answer 2

Correct Answers:

Respiratory alkalosis due to hyperventilation

Rationale :

🌸 The client's pH is 7.48, which is above the normal range of 7.35–7.45, indicating alkalemia.

🌸 The PaCO₂ is 30 mm Hg, which is below the normal range of 35–45 mm Hg, indicating excessive carbon dioxide elimination.

🌸 Because CO₂ acts as an acid, losing excessive CO₂ causes the blood pH to increase.

🌸 This pattern occurs with hyperventilation, when ventilation exceeds the body's metabolic requirement for carbon dioxide removal.

🌸 The HCO₃⁻ is 24 mEq/L, which remains within the normal range of approximately 22–26 mEq/L.

🌸 A normal bicarbonate level suggests that significant renal compensation has not yet occurred, supporting an acute or uncompensated respiratory process.

🌸 Common causes of respiratory alkalosis include anxiety, pain, fever, hypoxemia, pulmonary embolism, and excessive mechanical ventilation.

🌸 The ABG pattern of ↑ pH + ↓ PaCO₂ + normal HCO₃⁻ therefore identifies uncompensated respiratory alkalosis caused by hyperventilation.

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Answer 3

Correct Answers:

Neuropathic pain

Rationale :

♦️ Phantom limb pain is pain perceived in a limb or body part that has been amputated.

♦️ It results from abnormal activity within the peripheral nerves, spinal cord, and brain, rather than from ongoing tissue injury in the missing limb.

♦️ Clients may describe the sensation as burning, shooting, tingling, cramping, or electric-like pain.

♦️ These qualities are characteristic of neuropathic pain, which arises from injury or dysfunction within the nervous system.

♦️ The brain can continue to interpret signals as if they are coming from the amputated extremity because the neural pathways representing that limb remain active.

♦️ Phantom sensations can occur without pain, but when the sensations are painful they are classified as a neuropathic pain syndrome.

♦️ Management may include medications used for neuropathic pain, along with approaches such as mirror therapy or desensitization techniques when appropriate.

♦️ The defining feature is pain caused by altered nerve processing, making neuropathic pain the best classification.

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Answer 4

Correct Answers:

2

Rationale :

✅ Formula

Tablets per dose = (Total daily dose ÷ Number of doses) ÷ Dose per tablet

✏️ Ordered = 2 g/day

✏️ Frequency = 2 doses/day

✏️ Available = 500 mg/tablet

✏️ 2 g × 1,000 = 2,000 mg/day

✏️ 2,000 mg ÷ 2 doses = 1,000 mg/dose

✏️ 1,000 mg ÷ 500 mg/tablet

= 2 tablets

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Answer 5

Correct Answers:

Lower the height of the solution container.

Rationale :

🎯 Abdominal cramping during an enema commonly occurs when the solution enters the colon too rapidly.

🎯 The flow rate of an enema is influenced by the height of the solution container above the client's rectum.

🎯 Lowering the container decreases hydrostatic pressure, which slows the rate at which fluid enters the colon.

🎯 A slower infusion reduces rapid intestinal distention, helping relieve cramping and discomfort.

🎯 The nurse can temporarily slow or pause the flow until the cramping subsides and then continue at a slower rate.

🎯 The client should be encouraged to take slow, deep breaths to promote relaxation during the procedure.

🎯 Cramping alone does not necessarily indicate that the enema must be discontinued completely unless the pain becomes severe or another complication is suspected.

🎯 Therefore, lowering the solution container is the most appropriate action to reduce pressure, slow fluid administration, and relieve the client's discomfort.

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Answer 6

Correct Answers:

Hypotension
Flat neck veins
Poor skin turgor

Rationale :

✅ Hypotension

🧿 Frequent vomiting and diarrhea cause substantial loss of water and electrolytes from the gastrointestinal tract.

🧿 Continued fluid loss decreases the client's intravascular circulating volume, producing hypovolemia.

🧿 As circulating volume falls, venous return and cardiac preload decrease.

🧿 Reduced preload can decrease stroke volume and cardiac output, resulting in hypotension.

🧿 The client may initially develop compensatory tachycardia as the body attempts to maintain adequate cardiac output.

🧿 The nurse should monitor blood pressure, including orthostatic changes, because worsening hypotension can indicate significant volume depletion.

✅ Flat neck veins

🧿 Neck vein assessment provides useful information about intravascular volume and right-sided cardiac filling pressure.

🧿 Significant gastrointestinal fluid loss reduces venous volume and central venous pressure.

🧿 Reduced venous return causes the jugular veins to appear flat or poorly distended.

🧿 This finding is consistent with hypovolemia rather than fluid volume excess.

🧿 Distended neck veins would suggest increased venous pressure and are more characteristic of conditions such as fluid overload or right-sided heart failure.

🧿 Flat neck veins therefore support the presence of fluid volume deficit caused by prolonged vomiting and diarrhea.

✅ Poor skin turgor

🧿 Poor skin turgor is a classic physical manifestation associated with dehydration and fluid volume deficit.

🧿 Loss of body water decreases the amount of fluid within the interstitial tissues.

🧿 The skin consequently becomes less elastic and may return slowly after being gently pinched.

🧿 Older adults naturally have reduced skin elasticity, so turgor should be interpreted carefully and assessed at an appropriate site such as the sternum or forehead.

🧿 Additional dehydration findings can include dry mucous membranes, thirst, decreased urine output, tachycardia, and weakness.

🧿 Three days of vomiting and diarrhea makes poor skin turgor an expected manifestation of significant fluid loss.

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Answer 7

Correct Answers:

The client grimaces when they move.

Rationale :

🌼 Grimacing is an objective indicator of pain because it can be directly observed by the nurse.

🌼 Objective findings are signs that can be seen, measured, or verified by another person.

🌼 Facial expressions such as grimacing, guarding, moaning, or protective movements can suggest that the client is experiencing discomfort.

🌼 These behaviors are especially useful when the client has difficulty communicating or describing pain.

🌼 Objective indicators can support the nurse’s assessment, but they do not replace the client’s own pain report.

🌼 Pain is fundamentally a subjective experience, so the client’s description remains the most reliable source when they can communicate.

🌼 The nurse should assess both observed behaviors and the client’s stated pain characteristics to obtain a complete picture.

🌼 Because grimacing is directly observable, it is the best example of an objective pain manifestation.

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Answer 8

Correct Answers:

Respiratory acidosis

Rationale :

✏️ COPD can impair effective alveolar ventilation, especially as the disease becomes more severe.

✏️ Reduced ventilation causes the client to retain carbon dioxide (CO₂) in the bloodstream.

✏️ Increased PaCO₂ raises the amount of carbonic acid in the blood and lowers the pH.

✏️ This produces respiratory acidosis, characterized by a low pH and elevated PaCO₂.

✏️ Clients with chronic COPD may develop renal compensation, with the kidneys retaining bicarbonate to help buffer the excess acid.

✏️ This compensation can bring the pH closer to normal even when PaCO₂ remains chronically elevated.

✏️ Worsening hypoventilation can overwhelm compensation and lead to acute-on-chronic respiratory acidosis.

✏️ The nurse should monitor ABG values, respiratory effort, mental status, and oxygenation for signs of worsening CO₂ retention.

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Answer 9

Correct Answers:

Reflex Incontinence

Rationale :

🖊️ Reflex incontinence occurs when neurologic damage disrupts normal voluntary control of the bladder.

🖊️ A spinal cord injury can interrupt communication between the bladder, spinal cord, and brain.

🖊️ The bladder may then contract automatically when it reaches a certain volume, causing involuntary urine leakage.

🖊️ The client may have little or no awareness of the need to urinate before bladder emptying occurs.

🖊️ This pattern is sometimes associated with a neurogenic bladder caused by neurologic impairment.

🖊️ Bladder assessment can include urinary pattern, residual urine volume, infection symptoms, and the client's neurologic status.

🖊️ Management may involve scheduled bladder emptying, intermittent catheterization, or other interventions depending on the type of neurogenic dysfunction.

🖊️ Urinary leakage directly associated with nerve damage following spinal cord injury therefore most strongly indicates reflex incontinence.

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Answer 10

Correct Answers:

11.2 mL per dose

Rationale :

✏️ The child weighs 33 lb, so the first step is converting pounds to kilograms because the prescription is written in mg/kg/day.

✏️ 33 lb ÷ 2.2 = 15 kg.

✏️ The prescribed daily dose is 150 mg/kg/day, so 15 kg × 150 mg/kg/day = 2,250 mg/day.

✏️ The medication is ordered every 6 hours, which means the child receives 4 doses per day.

✏️ 2,250 mg/day ÷ 4 doses = 562.5 mg per dose.

✏️ The available concentration is 250 mg in 5 mL, which equals 50 mg/mL.

✏️ 562.5 mg ÷ 50 mg/mL = 11.25 mL per dose.

✏️ Rounded appropriately, the nurse should administer 11.2 mL per dose.

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QLexNursing

1 :
A nurse is assessing a client who is experiencing respiratory acidosis. Which of the following manifestations should the nurse expect to observe?

2 :
A client presents with the following arterial blood gas (ABG) results: pH 7.48, PaCO2 30 mm Hg, HCO3? 24 mEq/L. Based on these findings and the clinical data, which acid-base imbalance should the nurse prioritize for intervention?

3 :
A nurse is caring for a client who has phantom limb pain. The nurse should identify the client is experiencing which type of pair

5 :
A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

6 :
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

7 :
A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

8 :
A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances?

9 :
A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

10 :
A child weighs 33 lb and is prescribed ampicillin 150 mg/kg/day IV, divided equally every 6 hours. The medication available is ampicillin 250 mg/5 mL. How many mL should the nurse administer per dose?

QLexNursing

1 : A nurse is assessing a client who is experiencing respiratory acidosis. Which of the following manifestations should the nurse expect to observe?

2 : A client presents with the following arterial blood gas (ABG) results: pH 7.48, PaCO2 30 mm Hg, HCO3? 24 mEq/L. Based on these findings and the clinical data, which acid-base imbalance should the nurse prioritize for intervention?

3 : A nurse is caring for a client who has phantom limb pain. The nurse should identify the client is experiencing which type of pair

5 : A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

6 : A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

7 : A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

8 : A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances?

9 : A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

10 : A child weighs 33 lb and is prescribed ampicillin 150 mg/kg/day IV, divided equally every 6 hours. The medication available is ampicillin 250 mg/5 mL. How many mL should the nurse administer per dose?

1 :
A nurse is assessing a client who is experiencing respiratory acidosis. Which of the following manifestations should the nurse expect to observe?

2 :
A client presents with the following arterial blood gas (ABG) results: pH 7.48, PaCO2 30 mm Hg, HCO3? 24 mEq/L. Based on these findings and the clinical data, which acid-base imbalance should the nurse prioritize for intervention?

3 :
A nurse is caring for a client who has phantom limb pain. The nurse should identify the client is experiencing which type of pair

5 :
A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

6 :
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

7 :
A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

8 :
A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances?

9 :
A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

10 :
A child weighs 33 lb and is prescribed ampicillin 150 mg/kg/day IV, divided equally every 6 hours. The medication available is ampicillin 250 mg/5 mL. How many mL should the nurse administer per dose?