A nurse is assessing a client who has recently started supplemental oxygen therapy. Which signs indicate that the therapy is ineffective? (Select all that apply)

Choice A reason: Anxiety and restlessness indicate ineffective oxygen therapy, as they suggest persistent hypoxia or hypercapnia. The brain senses inadequate oxygenation, triggering a stress response, indicating the need for adjusted oxygen delivery or investigation into underlying respiratory issues, making this a sign of therapy failure.

Choice B reason: Pink, warm skin indicates adequate oxygenation and perfusion, suggesting effective oxygen therapy. Cyanosis or cool skin would signal hypoxia. This finding reflects successful correction of oxygen deficits, making it an incorrect choice for indicating ineffective therapy in this client with supplemental oxygen.

Choice C reason: A heart rate of 58 (bradycardia) is not a primary indicator of ineffective oxygen therapy. Severe hypoxia typically causes tachycardia, while bradycardia may reflect other issues like medication effects, not directly oxygen therapy failure, making it less relevant in this context.

Choice D reason: A respiratory rate of 36 (tachypnea) indicates ineffective oxygen therapy, as rapid breathing reflects the body’s attempt to compensate for hypoxia or hypercapnia. This suggests insufficient oxygen delivery, requiring adjustment of oxygen flow or evaluation for respiratory issues, marking therapy failure.

Choice E reason: Use of accessory muscles indicates ineffective oxygen therapy, reflecting increased work of breathing due to persistent hypoxia or airway obstruction. Muscles like the sternocleidomastoid are recruited when primary respiratory muscles fail to maintain adequate oxygenation, signaling the need for immediate intervention.