The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?

The patient’s blood pressure is 164/98.

The patient’s oxygen saturation is 90%.

The patient reports feeling weak.

The patient appears somnolent and difficult to arouse.

Answer and Explanation

The Correct Answer is D

Choice A reason: Blood pressure of 164/98 mmHg is elevated but not immediately life-threatening in respiratory failure. It may reflect stress or chronic hypertension, less urgent than neurologic changes signaling CO2 narcosis.

Choice B reason: Oxygen saturation of 90% is low but manageable with oxygen therapy in respiratory failure. It’s concerning, yet less critical than somnolence, which indicates severe CO2 retention requiring urgent intervention.

Choice C reason: Weakness is nonspecific in respiratory failure, possibly from hypoxia or fatigue. It’s not as immediately alarming as somnolence, which directly reflects brain suppression from high PaCO2, needing prompt reporting.

Choice D reason: Somnolence and difficulty arousing signal CO2 narcosis from hypercapnia (high PaCO2), a medical emergency. It indicates respiratory acidosis impairing brain function, requiring immediate provider notification for ventilatory support.

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

Explanation

Choice A reason: Identifying triggers (e.g., allergens, exercise) prevents asthma exacerbations by avoiding bronchoconstriction causes. It empowers Sara to control exposure, a cornerstone of asthma education supported by evidence for long-term management success.

Choice B reason: Health promotion, like vaccinations and smoking cessation, reduces asthma triggers and infections. It strengthens overall respiratory health, a key teaching point to minimize exacerbations and improve Sara’s quality of life.

Choice C reason: Stress management reduces anxiety, a known asthma trigger via hyperventilation or vagal response. Techniques like deep breathing help Sara maintain control, making it a vital component of comprehensive asthma education.

Choice D reason: Keeping a journal tracks symptoms, triggers, and medication use, aiding asthma control. It provides data for healthcare adjustments, empowering Sara with self-monitoring, a proven strategy in personalized asthma management plans.

Choice E reason: Starting a running program risks exacerbating asthma via exercise-induced bronchospasm, especially without control. It’s not suitable teaching; gradual activity with medical clearance is safer, not an initial recommendation.

A. A 40-yr-old with a pleural effusion who reports chest discomfort B. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet C. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion D. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101°F (38.3°C)

Correct Answer is C

Explanation

Choice A reason: Pleural effusion with chest discomfort suggests fluid buildup, causing pain but not immediate airway compromise. It’s stable compared to tracheal deviation, prioritizing respiratory distress over this less acute issue.

Choice B reason: Cor pulmonale with 4+ edema indicates chronic right heart failure, a serious but slower process. It’s less urgent than acute airway obstruction, as it’s manageable with diuretics, not an immediate threat.

Choice C reason: Tracheal deviation post-catheter insertion signals tension pneumothorax, a life-threatening emergency. It compresses airways and vessels, requiring immediate assessment and intervention to restore breathing and circulation.

Choice D reason: Fever of 101°F post-lung transplant suggests infection or rejection, critical but not airway-immediate. It’s urgent, yet tracheal deviation’s acute respiratory collapse takes precedence over this systemic concern.

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The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following items should the nurse include in teaching Sara about asthma? (Select all that apply)

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

Explanation

After change-of-shift report, which patient would the nurse assess first?

Correct Answer is C

Explanation

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