Which clinical finding is most indicative of hypoxemic respiratory failure?

PaCO2 greater than 50 mm Hg

Bradycardia

PaO2 less than 60 mm Hg

Peripheral edema

Answer and Explanation

The Correct Answer is C

Choice A reason: PaCO2 greater than 50 mm Hg indicates hypercapnia, characteristic of hypercapnic respiratory failure due to hypoventilation, as seen in COPD or neuromuscular disorders. Hypoxemic respiratory failure is defined by low oxygen levels (PaO2 <60 mm Hg) with normal or low PaCO2, making hypercapnia less relevant.

Choice B reason: Bradycardia is not a primary feature of hypoxemic respiratory failure. Hypoxemia typically causes tachycardia as a compensatory response to low oxygen delivery. Bradycardia may occur in severe, late-stage hypoxia but is not the most indicative finding compared to PaO2, which directly measures oxygenation status.

Choice C reason: Hypoxemic respiratory failure is defined by a PaO2 less than 60 mm Hg, indicating severe impairment in oxygen transfer due to conditions like ARDS or pulmonary edema. This low arterial oxygen level, despite adequate ventilation, is the hallmark finding, requiring urgent intervention to restore tissue oxygenation.

Choice D reason: Peripheral edema suggests fluid overload, often seen in heart failure, which may contribute to pulmonary edema and hypoxemia. However, it is not a direct indicator of hypoxemic respiratory failure. PaO2 <60 mm Hg specifically defines the condition, as it reflects the primary issue of inadequate oxygenation.

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

Choice A reason: Tracheostomy is used for long-term airway management in chronic respiratory failure or airway obstruction. A respiratory rate of 6 breaths/min and SpO2 of 88% with lethargy indicate acute respiratory failure requiring immediate ventilatory support. Tracheostomy is invasive and time-consuming, making it less suitable than intubation for acute stabilization.

Choice B reason: A respiratory rate of 6 breaths/min, SpO2 of 88%, and increasing lethargy indicate severe hypoventilation and hypoxemia, risking respiratory arrest. Endotracheal intubation with mechanical ventilation ensures airway protection and adequate gas exchange, correcting CO2 retention and hypoxemia. This is the most effective intervention for acute respiratory failure in this critical scenario.

Choice C reason: Continuous positive airway pressure (CPAP) supports breathing in patients with adequate respiratory effort, like in obstructive sleep apnea. A respiratory rate of 6 breaths/min and lethargy suggest inadequate ventilation, requiring controlled mechanical support. CPAP is non-invasive but insufficient for severe hypoventilation, making it inappropriate for this acute situation.

Choice D reason: A non Yvonne-rebreather mask delivering 100% O2 can improve hypoxemia but does not address hypoventilation (respiratory rate 6 breaths/min) or CO2 retention, which contribute to lethargy. Mechanical ventilation via intubation is needed to correct both hypoxemia and hypercapnia, making this a less effective intervention for the client’s critical condition.

A. Administer IV insulin B. Initiate oral glucose administration C. Administer IV sodium bicarbonate D. Restrict fluid intake

Correct Answer is A

Explanation

Choice A reason: In DKA, hyperglycemia and ketoacidosis cause fruity breath and Kussmaul respirations (rapid, deep breathing) as the body compensates for acidosis. IV insulin halts ketone production, corrects hyperglycemia, and reverses acidosis, addressing the primary metabolic disturbance. This is the priority intervention to stabilize the client and prevent further acid-base imbalance.

Choice B reason: Oral glucose administration is contraindicated in DKA, as it worsens hyperglycemia. Fruity breath and Kussmaul respirations indicate severe metabolic acidosis from ketone accumulation. Insulin is needed to lower blood glucose and stop ketogenesis, making glucose administration harmful and inappropriate for managing this life-threatening condition.

Choice C reason: IV sodium bicarbonate may correct severe acidosis (pH <7.0) in DKA but is not the first-line intervention. Insulin therapy addresses the root cause by reducing hyperglycemia and ketone production, naturally correcting pH. Fruity breath and respirations indicate ongoing acidosis, making insulin the priority over bicarbonate in initial management.

Choice D reason: Restricting fluid intake is contraindicated in DKA, which causes dehydration from osmotic diuresis. Fruity breath and Kussmaul respirations reflect acidosis and compensatory hyperventilation. IV fluids and insulin are needed to restore volume and correct metabolic imbalances, making fluid restriction harmful and inappropriate for this critical condition.

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

Which clinical finding is most indicative of hypoxemic respiratory failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The client is increasingly lethargic. Which intervention will the nurse anticipate?

Correct Answer is B

Explanation

A client with diabetic ketoacidosis (DKA) is admitted to the ICU. The nurse notes a fruity breath odor and rapid, deep respirations. Which intervention should the nurse prioritize?

Correct Answer is A

Explanation

A nurse is caring for a client with a traumatic brain injury in the ICU. The client’s intracranial pressure (ICP) is 22 mm Hg. Which intervention should the nurse implement first?

While the client's full-thickness burn wounds to the face and body are exposed, what is the best nursing action to prevent cross-contamination?

A client in severe pulmonary edema is being intubated by the resident. What action by the nurse will assist in the confirmation of the endotracheal tube placement in the proper position?

A nurse is caring for a client with septic shock. The client’s blood pressure is 80/50 mm Hg, and lactate levels are elevated. Which intervention is the nurse’s priority?

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his neck, chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

The critical care nurse recognizes that which of the following conditions may indicate the need for a client to have a tracheostomy?

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?