When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

The patient's blood pressure is 164/98.

The patient appears somnolent.

The patient's oxygen saturation is 90%.

The patient reports feeling weak.

Answer and Explanation

The Correct Answer is B

B Somnolence, or excessive sleepiness, can indicate respiratory depression, hypercapnia (elevated PaCO2), or impending respiratory failure. Somnolence in this context is concerning as it may suggest worsening respiratory status and impending respiratory compromise. Therefore, it should be immediately reported to the healthcare provider for further evaluation and intervention.

A blood pressure of 164/98 mmHg is elevated but may not necessarily require immediate intervention, especially if the patient is not exhibiting signs of acute hypertensive crisis or end-organ damage.

However, it should be closely monitored and managed as appropriate. While hypertension may contribute to respiratory distress, it may not be the most critical finding to report immediately in a patient with possible respiratory failure and a high PaCO2.

C An oxygen saturation of 90% indicates hypoxemia, which can exacerbate respiratory failure and contribute to respiratory distress. While hypoxemia requires prompt intervention to improve oxygenation, it may not be the most critical finding to report immediately if the patient is not showing signs of severe respiratory distress or impending respiratory failure. However, it should be closely monitored and managed to prevent further deterioration.

D Weakness is a nonspecific symptom and may be related to various underlying causes, including respiratory failure, electrolyte imbalances, or systemic illness. While weakness warrants further assessment and management, it may not be the most urgent finding to report immediately in a patient with possible respiratory failure and a high PaCO2 unless it is accompanied by other concerning symptoms or signs of impending respiratory compromise.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

B. Sodium nitroprusside is a potent vasodilator used to reduce systemic vascular resistance and afterload, thereby improving cardiac output and tissue perfusion in cardiogenic shock. In this scenario, where the patient has cool and clammy skin with high SVR, indicating peripheral vasoconstriction,

increasing the rate of sodium nitroprusside infusion can help vasodilate peripheral vessels, reduce afterload, and improve tissue perfusion

A. Dopamine is a medication commonly used in the management of cardiogenic shock to increase cardiac output and systemic blood pressure. However, in this scenario where the patient is cool and clammy with high SVR, indicating vasoconstriction and potential peripheral hypoperfusion, increasing the rate of dopamine infusion may further increase systemic vascular resistance and exacerbate peripheral vasoconstriction. This can worsen tissue perfusion and exacerbate the patient's condition.

C. Nitroglycerin is another vasodilator commonly used in the management of cardiogenic shock to reduce preload and afterload, thereby improving cardiac output and tissue perfusion. However, decreasing the rate of nitroglycerin infusion may further exacerbate vasoconstriction and increase SVR, worsening tissue perfusion in this scenario. Therefore, decreasing the rate of nitroglycerin infusion is not indicated.

D. Intravenous fluids such as 5% dextrose in normal saline are typically administered to maintain adequate intravascular volume and perfusion pressure in shock states. However, decreasing the rate of intravenous fluid infusion may further decrease intravascular volume and preload, potentially exacerbating hypoperfusion and worsening the patient's condition. Therefore, decreasing the rate of intravenous fluid infusion is not indicated in this scenario.

A. Pulmonary artery wedge pressure (PAWP) is low. B. Systemic vascular resistance (SVR) is elevated. C. Mean arterial pressure (MAP) is 56 mm Hg D. Heart rate is slow at 58 beats/min.

Correct Answer is C

Explanation

C. Mean arterial pressure (MAP) reflects the average pressure in the arteries during one cardiac cycle and is an important indicator of tissue perfusion. A MAP of 56 mm Hg is below the normal range (typically >60 mm Hg) and may indicate inadequate tissue perfusion. While norepinephrine is commonly used to increase blood pressure and improve tissue perfusion in hypotensive patients, a MAP of 56 mm Hg suggests that the current infusion rate may not be sufficient to maintain adequate perfusion, and adjusting the infusion rate may be warranted.

A. Norepinephrine is a vasopressor medication primarily used to increase blood pressure in patients with hypotension or shock. A low pulmonary artery wedge pressure (PAWP) suggests decreased preload, which may indicate hypovolemia or inadequate fluid resuscitation. In this case, adjusting the norepinephrine infusion rate may not be necessary, but rather addressing the underlying cause of hypovolemia or inadequate preload.

B. Systemic vascular resistance (SVR) represents the resistance the heart must overcome to pump blood into the systemic circulation. An elevated SVR may suggest vasoconstriction, which could be a desired effect of norepinephrine infusion to increase blood pressure. Therefore, an elevated SVR may not necessarily indicate a need to adjust the norepinephrine infusion rate, as it may reflect the medication's intended action.

D. Norepinephrine primarily acts on alpha-adrenergic receptors to increase blood pressure by inducing vasoconstriction. While it may cause reflex bradycardia due to increased systemic vascular resistance, a heart rate of 58 beats/min may be within an acceptable range depending on the patient's clinical condition and baseline heart rate. Therefore, a slow heart rate alone may not necessarily indicate a need to adjust the norepinephrine infusion rate unless it is associated with signs of inadequate tissue perfusion or other concerning symptoms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

Correct Answer is B

Explanation

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted?

Correct Answer is C

Explanation

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

A nurse is caring for a 73-year-old client in the emergency department (ED) Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Which action should the nurse take first when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning?

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?