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.

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

Explanation

Choice A reason: Initiating a bowel regimen program is essential to avoid constipation, which can be a trigger for autonomic dysreflexia in patients with spinal cord injuries. Ensuring regular bowel movements helps prevent the discomfort and complications that can lead to this potentially life-threatening condition.

Choice B reason: Applying tight-fitting clothing is contraindicated as it can cause skin irritation, pressure sores, and other discomforts that could trigger autonomic dysreflexia. Loose and comfortable clothing is recommended to prevent these issues.

Choice C reason: Completing frequent skin checks is crucial for detecting and preventing pressure ulcers, skin infections, and other skin conditions that can act as noxious stimuli, triggering autonomic dysreflexia. Regular skin assessments help ensure early identification and management of potential issues.

Choice D reason: Restricting all patient visitors is not necessary for preventing autonomic dysreflexia. While it is important to manage the patient's environment and stress levels, complete visitor restriction is not a standard intervention for this condition.

Choice E reason: Inserting an indwelling Foley catheter is beneficial for managing bladder function and preventing urinary retention, a common trigger for autonomic dysreflexia. Continuous bladder drainage helps prevent distention and the subsequent risk of triggering this condition.

A. You will not need vascular access to perform PD. B. This can be done in the comfort of your home. C. You will have no risk for infection with PD. D. You have some flexibility in when you do the exchanges. E. It takes less time than hemodialysis treatments.

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

Explanation

Choice A reason: Not needing vascular access to perform PD is a significant advantage for patients. Peritoneal dialysis uses the peritoneal membrane in the abdomen as a filter to clean the blood, which eliminates the need for vascular access, such as fistulas or catheters required in hemodialysis. This can reduce the risks associated with vascular access, such as infections and complications related to surgical procedures.

Choice B reason: Being able to perform PD in the comfort of one's home is a major benefit. Patients can manage their dialysis treatments at home, which offers more convenience and flexibility compared to traveling to a dialysis center for hemodialysis sessions. This can greatly improve the quality of life and reduce the burden of frequent trips to healthcare facilities.

Choice C reason: Stating that there is no risk for infection with PD is inaccurate. While PD offers many benefits, it does carry a risk of peritonitis, an infection of the peritoneal cavity. Patients must be educated on proper technique and hygiene to minimize this risk. Hence, this statement is not accurate and should not be included as an advantage.

Choice D reason: Having flexibility in when to do the exchanges is another benefit of PD. Patients can schedule their dialysis exchanges at times that best fit their lifestyle and daily routines. This flexibility allows for greater independence and freedom compared to the fixed schedules required for in-center hemodialysis.

Choice E reason: PD can take less time than hemodialysis treatments, especially when considering travel and waiting times associated with in-center hemodialysis. Although the actual dialysis process for PD requires regular exchanges throughout the day or night, it integrates more seamlessly into daily life, making it a time-efficient option for many patients.

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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?

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Explanation

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Explanation

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