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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Providing at least 5000 kcal/day is essential for a patient with burn injuries. Burns significantly increase the body's metabolic rate and caloric needs to support the healing process and prevent catabolism. Ensuring an adequate caloric intake helps meet the energy demands required for tissue repair and recovery.

Choice B reason: Starting an oral diet on the first day may not be appropriate for all burn patients, particularly those with extensive burns or those who are not yet stable. Nutrition needs should be carefully assessed, and feeding may begin via alternative methods such as enteral nutrition until the patient is ready for oral intake.

Choice C reason: Administering a diet high in protein is crucial for burn patients, as protein is essential for wound healing, maintaining lean body mass, and supporting the immune system. Protein intake should be increased to help repair damaged tissues and promote recovery.

Choice D reason: Collaborating with a registered dietitian is important to create an individualized nutrition plan that meets the specific needs of the burn patient. A dietitian can provide expertise in calculating caloric and protein requirements, recommending appropriate supplements, and monitoring the patient's nutritional status.

Choice E reason: Offering frequent high-calorie snacks helps ensure that the patient meets their increased caloric needs. Small, frequent meals and snacks can be more manageable for patients with reduced appetite or those who have difficulty consuming large meals. High-calorie snacks provide additional energy to support healing and recovery.

A. The client's albumin level is increased. B. The client's platelet count is normal. C. The dressing has a 2-cm area of serous drainage. D. The client's heart rate is 122 beats/min.

Correct Answer is D

Explanation

Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.

Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.

Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.

Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

Correct Answer is D

Explanation

Which specific drug therapy will the nurse anticipate for management of the client who has septic shock?

A nurse is caring for a postoperative 70-kg patient who had major blood loss during surgery and now has acute kidney injury. The patient does not have signs of fluid overload. Which intervention would be most effective as a fluid challenge to promote kidney perfusion?

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? Select all that apply.

The nursing care priorities for the patient with burn injuries include wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is most likely in which phase of burn care?

A nurse in the emergency room is performing an assessment on a burn victim. She notes his face is a cherry-red color and suspects which of the following problems?

The healthcare provider recommends to a patient that diagnostic testing be performed to assess for valvular heart disease. The nurse teaches the patient about which test that is commonly used to assess the valves?

To prevent the most common serious complication of peritoneal dialysis, it is important for the nurse to: