A patient with respiratory failure has a respiratory rate of 26 breaths/min and an oxygen saturation (SpO2) of 80%. The patient is increasingly pale and restless but follows commands. Which intervention will the nurse anticipate?

Initiation of continuous positive pressure ventilation (CPAP)

Endotracheal intubation and positive pressure ventilation

Insertion of a mini-tracheostomy with frequent suctioning

Administration of 100% O2 by non-rebreather mask

Answer and Explanation

The Correct Answer is B

B. Endotracheal intubation and positive pressure ventilation are indicated in patients with respiratory failure who are unable to maintain adequate oxygenation or ventilation with non-invasive interventions. Intubation allows for the delivery of positive pressure ventilation, oxygenation, and airway protection. It also facilitates the clearance of secretions and administration of medications. Given the patient's severe hypoxemia, impending respiratory distress, and deteriorating condition, endotracheal intubation and positive pressure ventilation are the most appropriate interventions to ensure adequate oxygenation and prevent further deterioration.

A. CPAP is a non-invasive ventilation modality that provides a continuous positive pressure to the airways throughout the respiratory cycle. While CPAP may be beneficial in certain cases of respiratory failure, it may not be sufficient for a patient with severe hypoxemia (SpO2 of 80%) and impending respiratory distress. CPAP is typically indicated for patients with conditions such as obstructive sleep apnea or mild to moderate respiratory failure.

C. Mini-tracheostomy may be considered in certain cases of upper airway obstruction or inadequate airway clearance. However, in this scenario, the patient's hypoxemia is likely due to severe respiratory failure rather than upper airway obstruction. While suctioning may be necessary to clear secretions, it does not address the underlying cause of hypoxemia or provide ventilatory support.

D. While administration of supplemental oxygen is important in the management of hypoxemia, a non- rebreather mask may not be sufficient for a patient with severe hypoxemia and impending respiratory distress. Non-rebreather masks can deliver high concentrations of oxygen but may not provide adequate positive pressure support or airway protection. In this case, endotracheal intubation and positive pressure ventilation are more appropriate to ensure adequate oxygenation and ventilation.

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Correct Answer is B

Explanation

B. In a closed chest drainage system, slow and steady bubbling in the suction control chamber is typically an expected finding, as it indicates that the suction is active and functioning properly

A. Checking the tubing connections for leaks or the suction control outlet on the wall might be necessary if there were signs of a problem with the system's function.

C. Checking the suction control outlet on the wall is a reasonable action to ensure that the suction source is functioning appropriately and delivering the prescribed suction pressure to the chest drainage system. If there are any issues with the suction control outlet, they should be addressed to maintain proper suction.

D. Clamping the chest tube is not indicated based solely on the presence of slow, steady bubbling in the suction control chamber. Clamping the chest tube could obstruct drainage and lead to complications such as tension pneumothorax or retained hemothorax.

A. Insertion of a pulmonary artery catheter B. Obtaining a ventilation-perfusion scan C. Drawing blood for arterial blood gases D. Positioning the patient for a chest x-ray

Correct Answer is A

Explanation

A. The insertion of a pulmonary artery catheter can help in assessing hemodynamic parameters and distinguishing between these two conditions. It provides direct measurement of pulmonary artery pressures, which can be elevated in the case of heart failure.

B. A ventilation-perfusion (V/Q) scan is used to evaluate ventilation and perfusion in the lungs. While it can help identify areas of ventilation-perfusion mismatch, it may not be the most appropriate initial test for distinguishing between ARDS and pulmonary edema.

C. Drawing blood for arterial blood gases is also a critical step as it helps in assessing the severity of hypoxemia and respiratory failure.

D. A chest x-ray can show the presence of bilateral opacities, which are indicative of ARDS when cardiac failure or fluid overload is not the primary cause. However, transthoracic echocardiography (TTE) is often performed to seek evidence of cardiac dysfunction when cardiogenic pulmonary edema cannot be excluded by clinical evaluation, laboratory findings, or imaging.

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A patient with respiratory failure has a respiratory rate of 26 breaths/min and an oxygen saturation (SpO2) of 80%. The patient is increasingly pale and restless but follows commands. Which intervention will the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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