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

Explanation

Choice A reason: Monitoring amylase and lipase levels is the best way to determine the effectiveness of treatment in a patient with pancreatitis. These enzymes are produced by the pancreas, and their levels in the blood increase significantly during an episode of pancreatitis. As treatment progresses and the inflammation of the pancreas decreases, the levels of these enzymes should return to normal. Therefore, checking the levels of amylase and lipase is a direct indicator of the patient's response to treatment.

Choice B reason: Hematocrit and hemoglobin levels are important for assessing overall blood volume and oxygen-carrying capacity, but they are not specific indicators of pancreatitis treatment effectiveness. While these levels can provide information about the patient's general health and hydration status, they do not specifically reflect changes in pancreatic inflammation.

Choice C reason: Red blood cell count is another measure of the blood's oxygen-carrying capacity and overall health, but like hematocrit and hemoglobin, it is not specific to pancreatitis. Changes in red blood cell count can occur due to various factors, but they do not provide direct information about the effectiveness of pancreatitis treatment.

Choice D reason: Serum uric acid levels are typically monitored in conditions such as gout or kidney stones, and they are not related to pancreatitis. Monitoring serum uric acid would not provide useful information about the patient's response to pancreatitis treatment.

A. Medicate the patient for pain. B. Allow the patient to rest quietly. C. Assess the patient for bleeding. D. Document the findings in the chart.

Correct Answer is C

Explanation

Choice A reason: Medicating the patient for pain is not the most appropriate immediate action in this situation. While pain management is important, the primary concern should be addressing the significant changes in heart rate and blood pressure, which may indicate a more serious underlying issue.

Choice B reason: Allowing the patient to rest quietly is not the appropriate response to the noted changes in vital signs. The increase in heart rate and drop in blood pressure are signs that require immediate investigation and intervention, rather than passive observation.

Choice C reason: Assessing the patient for bleeding is the most appropriate action. The increase in heart rate and decrease in blood pressure following an angioplasty procedure are concerning for potential bleeding or hemorrhage, especially if the patient has an intra-arterial line. Quick assessment and intervention are crucial to address any bleeding and stabilize the patient's condition.

Choice D reason: Documenting the findings in the chart is necessary, but it should not be the immediate priority. The nurse must first assess and address the potential cause of the changes in vital signs, such as bleeding, before documenting the events.

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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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Naxlex Comprehensive Predictor Exams

To determine treatment effectiveness in a patient with pancreatitis, the nurse should monitor which of these tests?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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