A nurse is assessing a client who has hypoxemic respiratory failure. Which of the following findings should the nurse expect?
Pulmonary edema
Opioid toxicity
Myasthenia gravis
Flail chest
The Correct Answer is A
A. Pulmonary edema: Pulmonary edema occurs when fluid accumulates in the lungs, impairing gas exchange and leading to hypoxemia. This condition is a common cause of hypoxemic respiratory failure, and patients often present with symptoms such as dyspnea, crackles on auscultation, and hypoxemia. The nurse would expect this finding in a client experiencing hypoxemic respiratory failure.
B. Opioid toxicity: Opioid toxicity can cause respiratory depression, but it typically leads to hypoventilation, which results in hypercapnic respiratory failure (elevated carbon dioxide levels) rather than hypoxemic respiratory failure. Therefore, while opioid toxicity affects breathing, it is not directly associated with hypoxemic respiratory failure.
C. Myasthenia gravis: Myasthenia gravis is a neuromuscular disorder that leads to muscle weakness, including respiratory muscles. While it can cause respiratory failure in severe cases, it does not directly cause hypoxemic respiratory failure. Respiratory failure in myasthenia gravis is often due to insufficient ventilation rather than impaired oxygenation, so this is not the expected finding in hypoxemic respiratory failure.
D. Flail chest: Flail chest occurs due to multiple rib fractures that result in a segment of the chest wall moving paradoxically, impairing ventilation. While this condition can lead to respiratory failure, it typically causes hypercapnic rather than hypoxemic respiratory failure. Therefore, it is less likely to be the cause of hypoxemic respiratory failure in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "The ability to insert an endotracheal tube": This competency refers to technical skills in airway management, not to addressing cultural concerns or preferences in care. The ability to insert an endotracheal tube is a skill that does not directly relate to the scenario of cultural sensitivity.
B. "The ability to precept another nurse": While precepting may involve teaching or guiding others, the discussion of gender preferences for care is related to cultural competency and collaboration in a healthcare setting, rather than mentoring another nurse.
C. "The ability to collaborate as a team member.": The scenario described highlights the need for the nurse to work with the provider and the client to address cultural concerns and ensure that the client feels comfortable with their care. Collaboration with the healthcare team is a key competency in providing culturally sensitive care.
D. "The ability to act as charge nurse" Being a charge nurse involves managing a team, but it is not specifically relevant to addressing the client's preferences regarding the gender of the provider. This issue is more about cultural competence and collaboration than charge nurse responsibilities.
Correct Answer is B
Explanation
A. Resorption of cerebrospinal fluid: Cerebrospinal fluid resorption is primarily regulated by pressure gradients within the brain and the arachnoid villi, not directly by mean arterial pressure.
B. Cerebral blood flow: Mean arterial pressure is a key factor in maintaining adequate cerebral perfusion. The brain requires a consistent blood supply, and if MAP falls too low, cerebral perfusion pressure drops, increasing the risk for brain ischemia and secondary injury after trauma.
C. Regulation of blood pressure: MAP is a measurement derived from blood pressure values, not a mechanism that regulates blood pressure itself. It reflects perfusion status rather than controlling it.
D. The client's intake and output needs: Intake and output are managed through fluid balance and kidney function. While MAP may indirectly influence renal perfusion, it is not the primary determinant of fluid management planning.
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