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?

Insertion of a tracheostomy with frequent suctioning

Endotracheal intubation and mechanical ventilation

Initiation of continuous positive airway pressure (CPAP)

Administration of 100% O2 by non-rebreather mask

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

Choice A reason: A respiratory rate of 10 breaths/min is slightly below normal (12-20 breaths/min) but may not necessitate a tracheostomy unless accompanied by other factors like airway obstruction or inability to protect the airway. Tracheostomy is typically reserved for prolonged ventilation needs, not isolated low respiratory rates.

Choice B reason: A client requiring permanent ventilation, such as in chronic neuromuscular diseases or severe lung injury, needs a tracheostomy to provide a stable, long-term airway. Unlike endotracheal tubes, tracheostomies reduce complications like vocal cord damage and improve patient comfort, making them the standard for prolonged mechanical ventilation.

Choice C reason: Dyspnea, or shortness of breath, indicates respiratory distress but does not inherently require a tracheostomy. It may be managed with oxygen or non-invasive ventilation. Tracheostomy is indicated for airway obstruction or prolonged ventilation, not transient symptoms like dyspnea, which can have multiple causes.

Choice D reason: Respiratory acidosis, due to elevated CO2 from hypoventilation, may require ventilatory support but not necessarily a tracheostomy. Non-invasive ventilation or temporary intubation may suffice. Tracheostomy is reserved for long-term airway management, making it less relevant for acute acidosis without evidence of prolonged ventilation needs.

A. A raised red rash around the fistula site B. Cold and numb sensation distal to the fistula site C. Foul-smelling drainage from the fistula site D. Pain in the right arm proximal to the fistula site

Correct Answer is B

Explanation

Choice A reason: A raised red rash around the fistula site may indicate infection or skin irritation, not venous insufficiency. Venous insufficiency involves impaired venous return, causing edema or stasis, not localized rashes. Infections require antibiotics, but coldness and numbness distal to the fistula suggest vascular compromise, a hallmark of venous or arterial issues.

Choice B reason: Cold and numb sensation distal to the fistula site indicates possible venous insufficiency or steal syndrome, where the fistula diverts blood flow, reducing distal perfusion. This causes ischemia, leading to coolness and sensory loss. Teaching this manifestation ensures early detection of vascular complications, critical for preserving fistula function and limb viability.

Choice C reason: Foul-smelling drainage suggests infection at the fistula site, a serious complication requiring immediate intervention. It is not related to venous insufficiency, which involves impaired venous return, not purulent discharge. Infections are caused by bacterial invasion, not vascular flow issues, making this an incorrect sign for venous insufficiency teaching.

Choice D reason: Pain proximal to the fistula site may indicate inflammation or thrombosis but is not specific to venous insufficiency. Venous insufficiency typically causes distal symptoms like edema or numbness due to poor venous return. Pain above the fistula is less likely to reflect venous flow issues, making it less relevant for this teaching.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?

Correct Answer is B

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