The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour ago. What action does the nurse take next?
a. Assess client's rate, rhythm, and depth of respiration.
b. Measure the client's pulse and blood pressure.
c. Document findings and continue to monitor.
d. Notify the physician as soon as possible.
A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia) but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse needs to have more data to report.
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