A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which assessment finding is the greatest concern?

PaO2 of 46 mm Hg (80-100 mm Hg)

lack of adventitious lung sounds

respirations of 20 breaths/min (12-20 breaths/min)

oxygen saturation of 95% on room air (95-100%)

Answer and Explanation

The Correct Answer is A

Rationale:

A. A PaO₂ of 46 mm Hg is critically low and indicates severe hypoxemia. Normal PaO₂ ranges from 80–100 mm Hg. A value of 46 mm Hg reflects significant impairment in oxygen exchange and can lead to tissue hypoxia, organ failure, and death if not treated immediately. Acute pancreatitis can lead to acute respiratory distress syndrome (ARDS) due to systemic inflammation and capillary leakage in the lungs. According to airway, breathing, and circulation (ABC) priority principles, impaired oxygenation is an immediate life-threatening condition and is the greatest concern.

B. Lack of adventitious lung sounds is not necessarily abnormal. Clear lung sounds can be present even in early respiratory compromise. The absence of crackles, wheezes, or rhonchi does not rule out hypoxemia. Therefore, this finding is not as concerning as a critically low PaO₂.

C. A respiratory rate of 20 breaths per minute is at the upper limit of normal (12–20 breaths/min). While it may suggest mild compensation or anxiety, it is not immediately life-threatening and does not indicate severe respiratory compromise by itself.

D. An oxygen saturation of 95% on room air is within normal limits. Although it should be monitored closely in a client with respiratory distress, this value alone does not indicate acute deterioration.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. Heat exhaustion typically presents with normal to slightly elevated body temperature, usually below 40°C. A core temperature above 40°C indicates heat stroke, a more severe heat-related illness that involves central nervous system dysfunction and potential organ failure. Therefore, a temperature of 40.9°C is not expected in heat exhaustion.

B. While tachycardia and hypotension can occur in heat exhaustion due to fluid and electrolyte loss, hot, dry skin is a hallmark of heat stroke, not heat exhaustion. In heat exhaustion, the body continues to sweat profusely as a compensatory mechanism to dissipate heat. The presence of dry skin would suggest progression to a more severe condition.

C. Profuse sweating and tachycardia are indeed common in heat exhaustion, reflecting dehydration and sympathetic nervous system activation. However, confusion or altered mental status is more characteristic of heat stroke, indicating central nervous system involvement. In true heat exhaustion, cognitive function is generally preserved, though the client may feel weak or fatigued.

D. These are classic signs of heat exhaustion, resulting from fluid and electrolyte loss and decreased perfusion due to prolonged heat exposure. Additional symptoms may include fatigue, muscle cramps, mild tachycardia, and pallor. The presence of intact mental status differentiates heat exhaustion from heat stroke. Early recognition and management with oral or IV fluids, cooling measures, and rest in a cool environment are essential to prevent progression.

A. Heart rate: 92/min B. Respiratory rate: 20/min C. BP: 122/58 mm Hg D. Oxygen saturation: 96% on room air E. Client rates pain as 3 on a 0 to 10 pain scale F. Bowel sounds hypoactive in all four quadrants. G. Client vomiting brown liquid and reports continuing nausea. H. Urinating without difficulty, urine is clear yellow.

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

Explanation

Correct Answers

Heart rate: 92/min is correct because this reflects improvement from the previous tachycardia of 109/min, indicating stabilization of the client’s hemodynamic status.
Respiratory rate: 20/min is correct because this shows improvement from the previous tachypnea of 26/min, indicating better respiratory function and decreased distress.
BP: 122/58 mm Hg is incorrect because the blood pressure remains unchanged from Day 1. While it is stable, it does not specifically demonstrate improvement.
Oxygen saturation: 96% on room air is correct because this is an improvement from 93% and indicates better oxygenation and respiratory status.
Client rates pain as 3 on a 0 to 10 pain scale is correct because pain has decreased from 8 to 3 following medication administration, indicating effective pain management and clinical improvement.
Bowel sounds hypoactive in all four quadrants is incorrect because hypoactive bowel sounds continue to reflect decreased gastrointestinal motility and do not demonstrate improvement.
Client vomiting brown liquid and reports continuing nausea is incorrect because ongoing vomiting and nausea indicate continued gastrointestinal irritation and do not represent progression.
Urinating without difficulty, urine is clear yellow is correct because adequate urine output and normal urine characteristics indicate improved hydration and renal perfusion.

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A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which assessment finding is the greatest concern?

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Naxlex Comprehensive Predictor Exams

An emergency department nurse assesses a client with heat exhaustion. Which findings should the nurse anticipate?

Correct Answer is D

Explanation

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

Explanation

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