A nurse is caring for a patient with respiratory distress. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply.

Pulse oximetry of 94% on room air

A PaO2 level below 60 mmHg

An ABG pH level of 7.35

An ABG CO2 level over 50 mmHg

A respiratory rate of over 16/minute

Answer and Explanation

Correct Answer : B,D

Rationale:

A. Oxygen saturation of 94% is slightly below normal but not indicative of respiratory failure, which is defined by severe hypoxemia (PaO2 < 60 mmHg) or hypercapnia (PaCO2 > 50 mmHg).

B. PaO2 < 60 mmHg on room air indicates hypoxemic respiratory failure (Type I). This reflects inadequate oxygenation despite adequate ventilation.

C. A normal pH does not indicate respiratory failure. Respiratory failure is associated with acidemia when CO2 retention occurs or hypoxemia is severe enough to affect tissue perfusion.

D. PaCO2 > 50 mmHg indicates hypercapnic respiratory failure (Type II), which occurs when the patient cannot ventilate adequately to remove CO2, often leading to respiratory acidosis.

E. While tachypnea may be a sign of respiratory distress, a rate over 16/min is not sufficient to define respiratory failure. Many patients can compensate for hypoxemia or hypercapnia with an increased respiratory rate before failure occurs.

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Correct Answer is D

Explanation

Rationale:

A. Notify the healthcare provider is incorrect as the first action. While the provider must be informed of potential ETT displacement, immediate assessment of the patient’s airway and lung sounds is the priority to ensure safety.

B. Obtain a STAT chest x-ray is incorrect as the first action. A chest x-ray is important for confirming tube placement, but you must first assess for clinical signs of airway compromise or hypoxia before imaging. Waiting for a chest x-ray could delay intervention if the tube has entered a mainstem bronchus.

C. Give the client something for anxiety is incorrect because the anxiety may be a response to hypoxia or airway obstruction, not a primary anxiety issue. Administering medication without assessing the underlying cause could delay critical intervention.

D. Listen to the client's lungs is correct. The first action is to assess breath sounds bilaterally to determine whether the tube has migrated into a mainstem bronchus, which typically causes absent or diminished breath sounds on one side. Immediate assessment of ventilation and oxygenation guides urgent interventions, such as repositioning the ETT, providing oxygen, or calling for help.

A. Stable vital signs and ABGS B. Pulse oximetry above 80% and stable vital signs C. Stable nutritional status and ABGS D. Normal orientation and level of consciousness

Correct Answer is A

Explanation

Rationale:
A. Stable vital signs and ABGs is correct. Successful weaning from mechanical ventilation depends on the patient’s ability to maintain adequate gas exchange and hemodynamic stability. Stable vital signs (heart rate, blood pressure, respiratory rate) indicate cardiovascular stability, and normal arterial blood gases (ABGs) demonstrate that the patient can maintain sufficient oxygenation (PaO₂) and ventilation (PaCO₂) without assistance. These are the most reliable physiological predictors of successful weaning.

B. Pulse oximetry above 80% and stable vital signs is incorrect because a PaO₂ corresponding to an SpO₂ of 80% indicates significant hypoxemia. Successful weaning generally requires adequate oxygenation (SpO₂ typically ≥90% on minimal oxygen support) to ensure tissue oxygen delivery. Stable vital signs alone are not sufficient if oxygenation is inadequate.

C. Stable nutritional status and ABGs is incorrect because while good nutrition supports overall recovery and respiratory muscle strength, it is not an immediate predictor for weaning readiness. ABGs are important, but nutritional status alone does not determine ventilator independence.

D. Normal orientation and level of consciousness is incorrect because cognitive status is supportive but not the primary determinant of weaning success. Patients can be sedated or temporarily altered in consciousness and still be physiologically ready if vital signs and ABGs are stable. Cognitive ability mainly affects cooperation during weaning trials rather than physiological readiness.

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A nurse is caring for a patient with respiratory distress. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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