Which intervention should be prioritized for a client experiencing acute hypoxemic respiratory failure?

Starting antibiotic therapy

Initiating bronchodilator therapy

Providing supplemental oxygen

Administering diuretics

Answer and Explanation

The Correct Answer is C

Choice A reason: Antibiotic therapy is appropriate for infections causing respiratory failure, such as pneumonia, but it addresses the underlying cause, not the immediate hypoxemia. Acute hypoxemic respiratory failure requires urgent correction of low oxygen levels to prevent organ damage, making antibiotics a secondary intervention compared to oxygen delivery.

Choice B reason: Bronchodilators treat bronchospasm in conditions like asthma or COPD, improving airflow. In acute hypoxemic respiratory failure, the primary issue is impaired oxygen diffusion, often due to alveolar damage or shunting, not bronchoconstriction. Bronchodilators may help specific cases but are not the first-line intervention for hypoxemia.

Choice C reason: Acute hypoxemic respiratory failure is defined by low PaO2 (<60 mmHg) despite adequate ventilation, often due to shunting or diffusion defects. Providing supplemental oxygen immediately increases alveolar oxygen levels, improving arterial oxygenation and preventing tissue hypoxia. This is the priority intervention to stabilize the patient before addressing underlying causes.

Choice D reason: Diuretics reduce fluid overload in conditions like pulmonary edema, which can contribute to hypoxemic respiratory failure. However, they do not directly correct hypoxemia and may take hours to act. Supplemental oxygen addresses the immediate threat of low oxygen levels, making diuretics a secondary consideration in acute management.

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: Pain medication is important for burn patients due to severe pain from exposed nerve endings. However, in the ABCDE approach, circulation (fluid status) takes precedence over pain management. A 30% burn causes significant fluid loss, risking hypovolemic shock, making IV fluids the priority to stabilize the patient before addressing pain.

Choice B reason: A 30% burn injury to the lower extremities causes significant plasma leakage, leading to hypovolemia and potential shock. Administering IV fluids, typically via the Parkland formula, restores intravascular volume, maintains blood pressure, and ensures organ perfusion. In the ABCDE approach, circulation is prioritized, making fluid resuscitation the first intervention.

Choice C reason: Cleaning and dressing burn wounds prevent infection, a major complication due to loss of the skin barrier. However, this is not the immediate priority in the acute phase. Fluid resuscitation addresses life-threatening hypovolemia first, as per the ABCDE approach, ensuring circulatory stability before wound care is initiated.

Choice D reason: A tetanus booster prevents infection from Clostridium tetani, especially in contaminated burns. While important, it is not the first priority in the acute management of a 30% burn. Fluid resuscitation addresses immediate life-threatening hypovolemia, which takes precedence over prophylactic measures like tetanus vaccination in the ABCDE framework.

A. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A client who has severe head injuries, respiratory rate 8/min, and is unresponsive D. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound

Correct Answer is D

Explanation

Choice A reason: A pregnant female with cuts and abrasions who is ambulatory has stable vital signs in the triage context. Minor injuries like cuts do not compromise airway, breathing, or circulation immediately. In mass casualty triage, she is a lower priority (green tag) compared to clients with life-threatening conditions like chest trauma.

Choice B reason: A simple femur fracture with scratches and emotional distress indicates pain and potential blood loss but not immediate life-threatening issues. Crying hysterically suggests intact neurological and airway status. In triage, this client is stable (yellow tag) compared to those with airway or breathing compromise, making them a lower priority.

Choice C reason: Severe head injuries with a respiratory rate of 8/min and unresponsiveness indicate neurological and respiratory compromise. This is critical, warranting a red tag, but the client with a chest wound and hissing sound suggests a tension pneumothorax, which can cause immediate cardiopulmonary collapse, taking precedence in triage due to rapid lethality.

Choice D reason: A chest wound with an audible hissing sound indicates a sucking chest wound or tension pneumothorax, a life-threatening emergency. Air entering the pleural space collapses the lung, impairing breathing and circulation. In mass casualty triage, this client requires immediate intervention (red tag) to seal the wound and restore respiratory function, making them the priority.

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 intervention should be prioritized for a client experiencing acute hypoxemic respiratory failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

Correct Answer is D

Explanation

A client's 24-hour urine for creatinine clearance reveals the client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m². What stage of chronic kidney disease is the client in?

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

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 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?

A nurse is caring for a client in the emergency department. Exhibits When assessing a client with suspected ventilatory failure, potential indicators include dropdown, dropdown, and dropdown

This is an extra credit question: A nurse is caring for a client receiving hemodialysis. Exhibits A nurse is for a client who has received hemodialysis. Which of the following assessment findings require follow-up?

The client with chronic renal failure has a glomerular filtration rate (GFR) of 40 mL/min/1.73 m², as measured by a 24-hour creatinine clearance. What is the nurse's interpretation of this finding?