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

A client with a respiratory rate of 10 breaths/min

A client who requires permanent ventilation

A client who exhibits symptoms of dyspnea

A client with respiratory acidosis

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

Choice A reason: IV corticosteroids reduce inflammation in conditions like autoimmune pancreatitis, but they do not address acute hypoxemia. Sudden dyspnea and low oxygen saturation (85%) in acute pancreatitis suggest complications like ARDS or pleural effusion, requiring immediate oxygenation. Corticosteroids act slowly and are not the priority for correcting life-threatening hypoxia in this scenario.

Choice B reason: Sudden dyspnea and oxygen saturation of 85% indicate acute hypoxemia, potentially from ARDS or pulmonary complications in pancreatitis. High-flow oxygen therapy increases alveolar oxygen, improving arterial PaO2 and preventing tissue hypoxia. The ABCDE approach prioritizes breathing, making this the first intervention to stabilize the client before addressing underlying causes.

Choice C reason: ERCP diagnoses or treats pancreatic duct obstructions, a potential cause of pancreatitis, but it does not address immediate hypoxemia. Dyspnea and low saturation require urgent oxygen delivery to prevent organ damage. ERCP is a diagnostic or therapeutic procedure, not an acute intervention for respiratory distress in this critical scenario.

Choice D reason: Increasing IV fluid rate supports hydration and perfusion in pancreatitis, preventing hypovolemia. However, it does not correct acute hypoxemia causing dyspnea and low saturation. The ABCDE approach prioritizes breathing, and high-flow oxygen is needed to address the immediate threat of hypoxia, making fluid adjustment a secondary intervention.

A. Notify the health care provider about the client's status B. Give the prescribed PRN sedative drug C. Use pulse oximetry to check the oxygen saturation D. Offer reassurance and reorient the client

Correct Answer is C

Explanation

Choice A reason: Notifying the provider is important but not the first action. Agitation in aspiration pneumonia may stem from hypoxemia, a life-threatening issue. The ABCDE approach prioritizes assessing breathing (oxygen saturation) to identify and correct hypoxemia before escalating to the provider, ensuring immediate intervention for a potentially reversible cause.

Choice B reason: Administering a PRN sedative may reduce agitation but risks masking underlying causes like hypoxemia, common in aspiration pneumonia. Sedatives can depress respiration, worsening hypoxia. The ABCDE approach prioritizes assessing oxygen status first to address life-threatening causes of agitation, making sedation a secondary consideration after evaluation.

Choice C reason: Agitation in aspiration pneumonia often results from hypoxemia due to alveolar inflammation and impaired gas exchange. Using pulse oximetry to check oxygen saturation is the first action in the ABCDE approach, as it assesses breathing and identifies hypoxia, a life-threatening condition requiring immediate oxygen therapy or ventilatory support to stabilize the client.

Choice D reason: Offering reassurance and reorientation addresses agitation’s psychological aspects but does not treat underlying physiological causes like hypoxemia. In aspiration pneumonia, agitation is likely due to low oxygen levels, which must be assessed first via pulse oximetry. The ABCDE approach prioritizes breathing over non-physiological interventions in acute respiratory distress.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with acute pancreatitis in the ICU. The client develops sudden dyspnea and oxygen saturation of 85%. Which intervention should the nurse prioritize?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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