The nurse is caring for a client with hypercapnic respiratory failure. The client is lethargic & slow to follow commands. Current vitals: BP 78/52. pulse 132. respirations 8, and pulse ox 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?

Insertion of a tracheostomy to maintain the airway

Use of noninvasive positive pressure ventilation (BIPAP)

Endotracheal intubation with mechanical ventilation

Administration of 50% Venturi mask

Answer and Explanation

The Correct Answer is B

A. Insertion of a tracheostomy to maintain the airway: This is not the first step in the management of hypercapnic respiratory failure. A tracheostomy is usually considered in cases where prolonged mechanical ventilation is required or for patients who need long-term airway support. It would not be immediately prescribed in this situation.

B. Use of noninvasive positive pressure ventilation (BIPAP): The client is showing signs of hypercapnic respiratory failure, indicated by lethargy, slow response to commands, and low oxygen saturation (pulse ox 84%) despite receiving oxygen via a Venturi mask. BIPAP (Bilevel Positive Airway Pressure) is a form of noninvasive ventilation that can help improve both oxygenation and ventilation by providing positive pressure to help the client breathe more effectively. It is often used in cases of hypercapnic respiratory failure, especially when the patient is alert enough to tolerate the mask.

C. Endotracheal intubation with mechanical ventilation: While this may be necessary if noninvasive ventilation (like BIPAP) is not effective, endotracheal intubation is typically considered when the patient is unable to tolerate noninvasive ventilation or if their respiratory failure worsens significantly. Given that the patient is still responsive (though lethargic), BIPAP would likely be tried first.

D. Administration of 50% Venturi mask: Increasing the oxygen concentration is unlikely to resolve the underlying issue of hypercapnia (elevated CO2 levels) in this patient. Hypercapnic respiratory failure is primarily due to inadequate ventilation, not just oxygen deficiency. Therefore, a higher concentration of oxygen may not be sufficient and would not address the need for improved ventilation.

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Correct Answer is A

Explanation

A. Blood pressure is 92/50: Nitroglycerin is a vasodilator, and one of its common side effects is a reduction in blood pressure. A blood pressure of 92/50 indicates hypotension, which could be dangerous, especially in a patient with a myocardial infarction. The nurse should report this immediately as further reduction in blood pressure could lead to inadequate perfusion of vital organs, including the heart, and worsen the patient’s condition.

B. Serum potassium is 5.1 mEq/L: A serum potassium level of 5.1 mEq/L is within the normal range (3.5–5.0 mEq/L). While potassium imbalances can affect cardiac function, this level is not dangerously high and would not warrant immediate intervention.

C. Heart rate is 90 beats/minute: A heart rate of 90 beats per minute is within normal limits for an adult. It does not require immediate intervention in the context of a myocardial infarction unless there are signs of arrhythmias or other concerning changes.

D. T wave depression on the electrocardiogram: T wave depression can be a normal finding in patients with myocardial infarction, especially in the early stages. While it can indicate ischemia, it does not require immediate reporting unless there are more severe changes on the ECG or the patient’s condition deteriorates.

A. Administering aggressive medical interventions to prolong life. B. Encouraging the patient to engage in physical therapy and exercise. C. Providing comfort care and managing symptoms according to patient's wishes. D. Providing respite care and support for the patient's family.

Correct Answer is C

Explanation

A. Administering aggressive medical interventions to prolong life: In the end stages of Huntington's Disease, aggressive medical interventions are generally not the priority. Huntington's is a progressive neurodegenerative disease, and prolonging life without regard to the patient's quality of life is usually not the focus. The emphasis in end-of-life care is on comfort and symptom management rather than aggressive treatments.

B. Encouraging the patient to engage in physical therapy and exercise: While physical therapy can be important earlier in the disease progression to help maintain function and mobility, in the end stages of Huntington's Disease, the patient's focus is more on comfort care. At this point, physical therapy may not be practical or helpful in improving quality of life, so it is not the primary consideration.

C. Providing comfort care and managing symptoms according to patient's wishes: This is correct. The most important consideration in end-of-life care for a patient with Huntington's Disease is to focus on comfort and symptom management. This includes addressing pain, managing emotional and psychological symptoms, and ensuring that care aligns with the patient's wishes, values, and goals. End-of-life care should prioritize maintaining dignity and ensuring the patient's comfort.

D. Providing respite care and support for the patient's family: While providing respite care and family support are very important aspects of caregiving, the most important consideration is the patient's comfort and managing symptoms in alignment with their wishes. Respite care for the family is important but is not the central focus of end-of-life care for the patient.

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The nurse is caring for a client with hypercapnic respiratory failure. The client is lethargic & slow to follow commands. Current vitals: BP 78/52. pulse 132. respirations 8, and pulse ox 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the physician immediately?

Correct Answer is A

Explanation

Which of the following is the most important consideration in end-of-life care for a patient diagnosed with Huntington's Disease?

Correct Answer is C

Explanation

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