A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?
Friction rub
Xerostomia
Agitation
Decreased end-tidal CO
The Correct Answer is C
Rationale:
A. Friction rub: A friction rub is a sound heard on auscultation, typically due to the rubbing of the pleurae, and is more associated with pleuritis or pleural effusion rather than respiratory failure.
B. Xerostomia: Xerostomia, or dry mouth, can be a side effect of medications or dehydration but is not directly an indication of respiratory failure.
C. Agitation: Agitation is a common early sign of respiratory failure. As oxygen levels decrease or carbon dioxide levels increase in the bloodstream, the body may respond with restlessness or agitation due to insufficient oxygenation to the brain.
D. Decreased end-tidal CO2: A decreased end-tidal CO2 can indicate poor ventilation or respiratory distress, but it is not as specific as agitation in signaling respiratory failure. Agitation is a more direct response to inadequate gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "I will weigh myself daily." Weighing oneself daily is a recommended practice for clients with heart failure to monitor fluid retention. It does not suggest a need for cardiac rehabilitation as it helps with self-management.
B. "I'm too tired to brush my teeth." This statement suggests severe fatigue and reduced physical functioning, indicating the need for cardiac rehabilitation. It can help improve endurance, strength, and overall quality of life.
C. "I hate how I feel all the time." This statement indicates dissatisfaction with the condition, but it does not suggest a specific need for cardiac rehabilitation. It may signal emotional distress or depression, but not necessarily a physical activity issue.
D. "I need to start eating a low-sodium diet." Eating a low-sodium diet is part of heart failure management, it does not indicate the need for cardiac rehabilitation. Diet changes are essential but don't directly relate to physical rehabilitation.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Chronic Kidney Disease (CKD): The elevated BUN and creatinine levels, along with the client's decreased urine output and fluid retention, suggest impaired kidney function, increasing the risk for chronic kidney disease, especially with underlying comorbidities.
B. Hyperglycemia: There are no signs or symptoms indicating hyperglycemia, so hyperglycemia is unlikely to be a concern in this case based on the presented findings.
C. Uremia: Uremia occurs when waste products accumulate in the blood due to renal dysfunction, and the elevated BUN and creatinine, combined with symptoms like fatigue and dyspnea, indicate this condition in the client.
D. Hyperkalemia: Impaired kidney function limits potassium excretion, increasing the risk for hyperkalemia. Given the client’s kidney impairment, this can lead to elevated potassium levels and potentially cause life-threatening arrhythmias.
E. Polycystic Kidney Disease: Polycystic kidney disease typically presents with a gradual onset of symptoms like kidney enlargement and a family history, which the client’s acute presentation does not support, making PKD an unlikely diagnosis.
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