A 35-year-old patient arrives at the Emergency Department in acute respiratory failure. What assessment information does the nurse prioritize as needing immediate action?
Respirations are labored and shallow.
PaO2 50 mmHg.
PaCO2 32 mmHg.
Respiratory rate 32 breaths/min.
The Correct Answer is A
Choice A reason: Labored and shallow respirations indicate that the patient is struggling to breathe and may not be ventilating effectively. This can quickly lead to respiratory fatigue and failure, and it requires immediate intervention to support the patient's airway and breathing.
Choice B reason: A PaO2 level of 50 mmHg is significantly low, indicating hypoxemia. This is concerning and requires attention, but the immediate visual and tactile signs of labored and shallow breathing take precedence as they are indicative of the patient's overall respiratory effort and ability to maintain adequate ventilation.
Choice C reason: A PaCO2 level of 32 mmHg is low and suggests hyperventilation. While this finding is important, it is not as immediately critical as labored and shallow respirations, which can quickly deteriorate into complete respiratory failure.
Choice D reason: A respiratory rate of 32 breaths/min indicates tachypnea, which is a sign of respiratory distress. However, the quality of respirations (labored and shallow) is a more immediate concern as it directly affects the patient's ability to ventilate and oxygenate effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A heart rate of 56/min and a blood pressure of 110/70, while slightly lower than normal, may not require immediate intervention unless accompanied by other symptoms. Bradycardia (a slow heart rate) and this blood pressure reading can be within acceptable limits for some individuals, especially if they are asymptomatic.
Choice B reason: Mitral valve regurgitation with a thready peripheral pulse indicates a decrease in cardiac output, which can be concerning. However, it may not require immediate intervention unless the client shows signs of severe decompensation or other critical symptoms. Continuous monitoring and evaluation are essential, but immediate action might not be necessary.
Choice C reason: Chest pain with inspiration in a client with pericarditis can be a symptom of the condition itself, which involves inflammation of the pericardium. While pain management and monitoring are important, this symptom alone may not necessitate immediate intervention unless it is severe or accompanied by other alarming signs.
Choice D reason: The development of slurred speech in a client with a history of atrial fibrillation is a critical symptom that warrants immediate intervention. Slurred speech can be a sign of a stroke or transient ischemic attack (TIA), both of which require urgent medical attention. Immediate action is needed to evaluate and manage the client's condition to prevent further complications.
Correct Answer is C
Explanation
Choice A reason: Albumin is a plasma expander and is typically used to restore blood volume in cases of shock, burns, or trauma. However, it is not specifically indicated for managing spinal shock. Albumin helps in maintaining osmotic pressure and fluid balance but does not directly address the underlying pathophysiology of spinal shock.
Choice B reason: Nitroprusside is a potent vasodilator used to manage hypertensive crises. It works by rapidly reducing blood pressure through vasodilation. In the context of spinal shock, where hypotension is a concern, administering nitroprusside would be inappropriate as it could exacerbate the hypotensive state and worsen the patient's condition.
Choice C reason: Dexamethasone, a corticosteroid, is used to reduce inflammation and edema around the spinal cord following an injury. The anti-inflammatory properties of dexamethasone help to mitigate secondary damage caused by swelling and pressure on the spinal cord tissue. It is commonly administered in cases of acute spinal cord injuries to improve neurological outcomes and manage symptoms of spinal shock.
Choice D reason: Furosemide is a diuretic used to manage fluid overload and edema. It works by increasing urine output, which can help reduce fluid retention in various conditions, such as heart failure and renal impairment. However, it is not specifically indicated for the management of spinal shock and does not address the underlying causes of spinal cord injury-related inflammation and edema.
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