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.

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Correct Answer is D

Explanation

Choice A reason: A heart rate of 122/min indicates tachycardia, possibly due to pain, stress, or hypovolemia in burn patients. While concerning, it is not the immediate priority unless accompanied by hemodynamic instability. The ABCDE approach prioritizes airway and breathing, and tachycardia is secondary to potential airway compromise indicated by difficulty swallowing.

Choice B reason: Urinary output of 25 mL/hr is below the desired 30-50 mL/hr in burn patients, suggesting possible hypovolemia or renal impairment. While important, it is a circulation issue in the ABCDE framework and less urgent than airway compromise, which can rapidly lead to life-threatening obstruction in a burn patient.

Choice C reason: Pain rated 6/10 is significant and requires management, especially in burn patients where pain is common due to nerve exposure. However, in the ABCDE approach, pain is addressed after airway, breathing, and circulation. It is not the immediate priority compared to a symptom suggesting airway compromise like difficulty swallowing.

Choice D reason: Difficulty swallowing in a burn patient with facial and airway burns suggests potential airway edema or obstruction, a critical emergency. Burns to the face, ears, and eyelids can cause swelling that compromises the airway, leading to rapid deterioration. This aligns with the ABCDE priority of airway assessment, requiring immediate reporting and intervention.

A. Blood pressure of 110/70 mm Hg B. Heart rate of 120 beats/min C. Warm, dry skin D. Urine output of 40 mL/hr

Correct Answer is B

Explanation

Choice A reason: Blood pressure of 110/70 mm Hg is within normal range and does not indicate hypovolemic shock, which typically presents with hypotension (e.g., <90/60 mm Hg). Early shock may have normal blood pressure, but tachycardia (heart rate 120 beats/min) is a more sensitive indicator of compensatory response to volume loss.

Choice B reason: Heart rate of 120 beats/min indicates tachycardia, a hallmark of hypovolemic shock. In trauma, blood loss reduces circulating volume, triggering sympathetic activation to increase heart rate, compensating for decreased cardiac output. This is the most indicative finding, as it appears early and reflects the body’s response to hypovolemia.

Choice C reason: Warm, dry skin is not typical of hypovolemic shock, which causes cool, clammy skin due to vasoconstriction from sympathetic activation. Warm skin may occur in distributive shock (e.g., sepsis). Tachycardia is a more specific indicator of hypovolemia, making this finding incorrect for the suspected condition.

Choice D reason: Urine output of 40 mL/hr is within normal range (30-50 mL/hr) and does not indicate hypovolemic shock, which typically reduces output (<30 mL/hr) due to decreased renal perfusion. Tachycardia (120 beats/min) is a more immediate and sensitive sign of hypovolemia, making urine output less indicative in early shock.

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Which clinical finding is most indicative of hypoxemic respiratory failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Correct Answer is D

Explanation

A nurse is assessing a client with suspected hypovolemic shock following trauma. Which clinical finding is most indicative of this condition?

Correct Answer is B

Explanation

While developing a care plan for a client with full thickness burns, the nurse determines an appropriate goal is to maintain alignment of joints. The goal is to prevent which of the following complications associated with full thickness burns?

A client with chronic obstructive pulmonary disease (COPD) is admitted with acute exacerbation and respiratory distress. Which finding requires immediate intervention by the nurse?

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