A client in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential extrapulmonary cause of ventilatory failure?

Amyloidosis

Pneumothorax

Pulmonary edema

Opioid analgesic overdose

Answer and Explanation

The Correct Answer is D

A. Amyloidosis can affect the lungs or heart and may contribute to respiratory failure, but this is generally considered a pulmonary or systemic disease causing intrapulmonary problems rather than an extrapulmonary cause of ventilatory failure.

B. Pneumothorax is a pulmonary cause of respiratory failure. It directly impairs lung expansion and gas exchange by causing air to accumulate in the pleural space.

C. Pulmonary edema is another pulmonary cause of respiratory failure. It occurs due to fluid accumulation in the alveoli, impairing oxygenation and ventilation.

D. Opioid analgesic overdose is an extrapulmonary cause of ventilatory failure. Opioids depress the central nervous system, particularly the medullary respiratory centers, leading to hypoventilation, decreased tidal volume, and elevated arterial CO₂ (hypercapnia). This is a classic example of ventilatory failure caused by a neurologic or pharmacologic extrapulmonary issue, rather than intrinsic lung disease.

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

Explanation

A. Safetyis a top priority because clients admitted from correctional facilities may present risks to themselves, staff, or othersdue to stress, aggression, or underlying medical or psychiatric conditions. Ensuring a safe environment involves constant assessment, monitoring, and awarenessof the client’s behavior and potential triggers. Safety measures protect both the client and healthcare team, and are essential in the emergency setting where acute and unpredictable situations are common.

B. Human dignitymust be maintained because every client, regardless of incarceration status, is entitled to ethical, respectful care. Preserving dignity involves addressing the client by name, respecting privacy, explaining procedures, and avoiding stigmatizing or judgmental behavior. Upholding dignity encourages client cooperation, reduces agitation, and supports positive healthcare outcomes, even in a secure setting.

C. Ambulatory careis not a priority in this scenario. Ambulatory care refers to outpatient or non-urgent care for clients who are mobile and can self-manage certain aspects of their care. In an emergency department, especially for a client coming from a correctional facility, the focus is on immediate safety, assessment, and stabilization, not outpatient care.

D. Compassionate careis essential because incarcerated clients may experience stress, fear, or mistrustin healthcare environments. Providing compassionate care involves listening, validating concerns, showing empathy, and responding to needswhile maintaining professional boundaries. Compassionate care improves compliance, reduces anxiety, and promotes therapeutic rapport, which is critical for effective treatment and assessment.

E. Secure environmentis crucial when caring for clients from penitentiaries. This includes ensuring that the client is monitored, potentially restrained if necessary, and kept in a controlled areato prevent escape or harm to staff and other patients. Security protocols must be integrated with nursing care to maintain safety without compromising ethical treatment or human dignity.

A. Pain rating of 3 on a scale of 0 to 10 by the client. B. Decreased client anxiety. C. Respiratory rate of 16 breaths/minute. D. PaO2 of 82 mm Hg.

Correct Answer is A

Explanation

A. The primary goal of administering hydromorphone IVis to relieve severe pain. A decrease in the pain score from 8/10 to 3/10 indicates that the analgesic intervention has been effective, allowing improved comfort and potentially better respiratory effort.

B. While reduced anxiety may occur as a secondary effectof pain relief, it is not a direct measureof the effectiveness of the opioid analgesic. Anxiety reduction alone does not confirm pain control.

C. Although maintaining a normal respiratory rate is important, opioids can depress respirations. The rate of 16 may reflect adequate breathing, but it does not directly measure pain relief. The client could still be in pain despite a normal respiratory rate.

D. Improvement in oxygenation may occur as a result of better ventilation after pain control, but it is an indirect indicator. PaO2 can be influenced by factors other than pain, such as the pneumothorax or underlying lung injury, so it does not confirm analgesic effectiveness.

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A client in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential extrapulmonary cause of ventilatory failure?

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Naxlex Comprehensive Predictor Exams

The emergency room nurse is caring for a client admitted from the penitentiary. What concepts will the nurse prioritize? Select all that apply

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

Explanation

The nurse is caring for a client with rib fractures and a pneumothorax who reports a pain score of 8/10. The nurse administered prescribed hydromorphone IV push and reassesses the client in 30 minutes. What data indicates that the treatment is effective?

Correct Answer is A

Explanation

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