The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?
The patient’s blood pressure is 164/98.
The patient’s oxygen saturation is 90%.
The patient reports feeling weak.
The patient appears somnolent and difficult to arouse.
The Correct Answer is D
Choice A reason: Blood pressure of 164/98 mmHg is elevated but not immediately life-threatening in respiratory failure. It may reflect stress or chronic hypertension, less urgent than neurologic changes signaling CO2 narcosis.
Choice B reason: Oxygen saturation of 90% is low but manageable with oxygen therapy in respiratory failure. It’s concerning, yet less critical than somnolence, which indicates severe CO2 retention requiring urgent intervention.
Choice C reason: Weakness is nonspecific in respiratory failure, possibly from hypoxia or fatigue. It’s not as immediately alarming as somnolence, which directly reflects brain suppression from high PaCO2, needing prompt reporting.
Choice D reason: Somnolence and difficulty arousing signal CO2 narcosis from hypercapnia (high PaCO2), a medical emergency. It indicates respiratory acidosis impairing brain function, requiring immediate provider notification for ventilatory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Repositioning may ease discomfort but won’t address severe pain (7/10) or reduced breath sounds post-thoracotomy. It risks dislodging tubes and doesn’t improve atelectasis or bleeding, lacking urgency for this acute scenario.
Choice B reason: Incentive spirometry prevents atelectasis, but pain limits participation. Decreased breath sounds suggest collapse, yet without pain control, this intervention is ineffective, delaying relief and lung expansion needed post-surgery.
Choice C reason: Clamping a chest tube risks tension pneumothorax by trapping air or blood, worsening breathing. With 100 mL drainage, it’s functioning; clamping is contraindicated unless ordered, making it dangerous here.
Choice D reason: Morphine reduces severe pain (7/10), enabling deeper breathing to reverse atelectasis. It addresses the primary barrier to recovery post-thoracotomy, improving ventilation and comfort, aligning with acute pain management protocols.
Correct Answer is A
Explanation
Choice A reason: Hospitalized patients often have immobility, surgery, or illness, increasing VTE risk via stasis, vessel injury, and hypercoagulability (Virchow’s triad). Studies show up to 60% of VTE cases occur in this setting, confirming the statement.
Choice B reason: False implies low VTE risk in hospitals, contradicting evidence. Inactivity and acute conditions elevate risk significantly, with prophylaxis standard in guidelines, as immobility alone triples clot formation likelihood.
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