A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?

Decreased end-tidal CO2

Agitation

Xerostomia

Friction rub

Answer and Explanation

The Correct Answer is B

A. Decreased end-tidal CO₂: A low end-tidal CO₂ level typically reflects hyperventilation or poor perfusion rather than respiratory failure. In early respiratory failure, CO₂ levels usually rise as the client experiences hypoventilation and impaired gas exchange.

B. Agitation: Agitation is an early sign of hypoxia as the brain becomes deprived of adequate oxygen. Clients often show restlessness, confusion, or behavioral changes before more obvious signs of respiratory failure appear, making this a critical early indicator.

C. Xerostomia: Dry mouth is a nonspecific finding that may result from dehydration, medications, or mouth breathing but does not reliably indicate respiratory failure. It lacks the clinical significance needed to identify deterioration in oxygenation or ventilation.

D. Friction rub: A friction rub suggests pleural inflammation rather than respiratory failure. While it may occur with some pulmonary conditions, it does not directly reflect the impaired oxygenation or ventilation associated with respiratory failure.

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Correct Answer is ["B","D","E","F"]

Explanation

A. Respiratory alkalosis: The client’s arterial pH is 7.30, indicating acidemia rather than alkalemia. Respiratory alkalosis is not expected in hyperglycemic crises; instead, metabolic acidosis may develop due to ketone accumulation and dehydration.

B. Hypotension: The client’s blood pressure is 96/65 mm Hg, which is lower than normal, likely related to dehydration from osmotic diuresis caused by severe hyperglycemia. Ongoing fluid loss increases the risk of hypotension, making it an important complication to monitor and manage promptly.

C. Septic shock: While the client has a recent history of bronchitis and pneumonia, there is no current evidence of infection such as fever, tachypnea, or elevated WBCs. Although infection could precipitate hyperglycemia, septic shock is not an immediate complication indicated by the current findings.

D. Cardiac arrhythmias: The client has a potassium level of 5.5 mEq/L, which is elevated. Hyperkalemia increases the risk of cardiac arrhythmias, especially in combination with dehydration and acidosis, making close cardiac monitoring necessary.

E. Renal failure: Elevated BUN (21 mg/dL) and creatinine (1.7 mg/dL) suggest impaired renal perfusion or acute kidney injury secondary to dehydration from osmotic diuresis. The client is at risk of progression to renal failure if fluid and electrolyte imbalances are not corrected.

F. Cerebral edema: Cerebral edema is often caused by an overly rapid drop in effective serum osmolarity during treatment, primarily when blood glucose is lowered too quickly. The rapid shift in fluid from the bloodstream to the brain cells can cause swelling.

A. “I seem to be bruising more easily," B. "I have to urinate frequently." C. "I have a nagging, dry cough." D. "I have a heightened sense of taste."

Correct Answer is C

Explanation

A. “I seem to be bruising more easily,”: Easy bruising is not a typical adverse effect of lisinopril. Bruising may indicate a hematologic issue or another medication effect, but it is unrelated to ACE inhibitor therapy.

B. "I have to urinate frequently.": Increased urination is not commonly associated with lisinopril. Diuretics, rather than ACE inhibitors, are more likely to cause polyuria. This statement does not indicate an adverse effect of lisinopril.

C. "I have a nagging, dry cough.": A persistent, dry cough is a well-known adverse effect of ACE inhibitors like lisinopril. It occurs due to the accumulation of bradykinin in the respiratory tract, and it can be bothersome enough to require medication adjustment or substitution.

D. "I have a heightened sense of taste.": Altered taste perception is not a common adverse effect of lisinopril. While some medications can affect taste, this is not characteristic of ACE inhibitors and is unlikely to be related to the client’s current therapy.

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A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?

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Explanation

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