The nurse is caring for a client with respiratory failure. The client is lethargic and slow to follow commands. Current vital signs are: BP 88/52, pulse 132, respirations 8, and SPO2 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?

Endotracheal intubation with mechanical ventilation

Use of bi-level positive airway pressure ventilation (BiPAP)

Administration of 100% oxygen by mask

Insertion of an oral airway device to maintain the airway

Answer and Explanation

The Correct Answer is A

A) Endotracheal intubation with mechanical ventilation:
Given the client’s lethargy, slow response to commands, and critical vital signs (e.g., low blood pressure of 88/52, high pulse rate of 132, respiratory rate of 8, and oxygen saturation of 84%), the client is in severe respiratory distress and may be at risk for respiratory failure. The low SpO2 of 84% on a 35% Venturi mask indicates that the client is not adequately oxygenating despite non-invasive oxygen support. In such situations, endotracheal intubation with mechanical ventilation is required to ensure adequate ventilation, oxygenation, and airway protection. This is the most appropriate intervention for a client in respiratory failure who is not responding to less invasive interventions like oxygen therapy or non-invasive ventilation.

B) Use of bi-level positive airway pressure ventilation (BiPAP):
BiPAP is a non-invasive ventilation option that is often used for patients with respiratory failure, particularly those with obstructive or central sleep apnea or those in the early stages of acute respiratory failure (e.g., chronic obstructive pulmonary disease exacerbations). However, given the client’s level of lethargy and deteriorating vital signs, BiPAP may not be sufficient. This client is showing signs of severe respiratory distress and requires more invasive management, such as endotracheal intubation and mechanical ventilation, to maintain an open airway and ensure adequate oxygenation and ventilation.

C) Administration of 100% oxygen by mask:
While oxygen administration is essential to manage respiratory failure, providing 100% oxygen via mask alone is unlikely to resolve the client's underlying issues, especially since the client’s oxygen saturation is critically low (84%) on 35% Venturi mask. Simply increasing the oxygen concentration will not be effective if the client’s respiratory failure is severe and the airway is compromised. More aggressive interventions, such as intubation, are necessary to manage the client’s airway and respiratory function appropriately.

D) Insertion of an oral airway device to maintain the airway:
An oral airway device is typically used for clients who are unconscious or semi-conscious to help keep the airway open. However, in this case, the client is lethargic but not fully unconscious, and the underlying issue is respiratory failure, not just a blocked airway. An oral airway device will not address the client’s inadequate ventilation or oxygenation and will not be sufficient to manage the client’s critical condition. The client requires intubation and mechanical ventilation to ensure adequate airway management and respiratory support.

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Correct Answer is C

Explanation

A. Call for the rapid response team and request a portable chest X-ray: While calling for assistance and obtaining a chest X-ray is important for further assessment, the immediate priority is to secure the wound to prevent air from entering the pleural space. This action will help stabilize the patient until the rapid response team arrives and the X-ray can be performed.

B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction and auscultating breath sounds may be necessary after the wound is secured, but these actions should not take priority over sealing the chest tube site. The focus at this moment is to prevent a tension pneumothorax by sealing the dislodged chest tube site. Auscultation of breath sounds is useful afterward to assess for respiratory complications, but it is not the first action to take.

C. Apply a sterile dressing and tape on three sides: The first action when a chest tube becomes accidentally dislodged is to seal the opening to prevent air from entering the pleural space, which could lead to a pneumothorax (collapsed lung). Applying a sterile dressing and taping it on three sides helps create a temporary one-way valve effect, allowing air to escape from the pleural space but preventing further air from being drawn in. This intervention is crucial to stabilize the patient while awaiting further evaluation and intervention.

D. Notify the healthcare provider immediately: Notifying the healthcare provider is essential, but it is not the first action. The most important initial step is to seal the chest tube site to prevent further complications. After the dressing is applied, the nurse can then notify the healthcare provider and continue to monitor the patient.

A. Encourage the daily use of the incentive spirometer B. Assisting the client with ambulation in the hallway C. Increasing the chest tube suction to 44 mmHg D. Assessing for adequate pain relief

Correct Answer is D

Explanation

A. Encourage the daily use of the incentive spirometer: While the use of an incentive spirometer is important for improving lung expansion and preventing atelectasis, it may not be effective unless the client’s pain is well-managed. If pain is not addressed first, the client may be unable or unwilling to use the incentive spirometer properly, thus delaying recovery and increasing the risk of respiratory complications.

B. Assisting the client with ambulation in the hallway: Ambulation is an important post-operative activity for improving circulation and preventing complications such as deep vein thrombosis (DVT) or pneumonia. However, the priority at this time should be addressing the client's pain and ensuring adequate breathing before attempting more strenuous activities like ambulation. If the client is in pain and not breathing effectively, ambulation could exacerbate respiratory difficulties..

C. Increasing the chest tube suction to 44 mmHg: Increasing chest tube suction is not indicated unless there is evidence of inadequate drainage or a specific complication, such as a pneumothorax or pleural effusion. In this case, the priority is to address the client’s respiratory function, which is more likely to improve with pain relief, deep breathing, and appropriate positioning. Suctioning should only be adjusted if there is a clinical reason such as signs of a pneumothorax or inadequate drainage, which is not indicated by the information provided.

D. Assessing for adequate pain relief: The most urgent intervention in this scenario is ensuring that the client has adequate pain relief. The client’s shallow respirations and guarding of the operative site suggest that pain is inhibiting effective breathing and deep inspiration, which is crucial for preventing atelectasis and improving ventilation. Pain control is essential in promoting optimal respiratory function, as uncontrolled pain can lead to shallow breathing, reduced lung expansion, and compromised gas exchange, all of which can increase the risk of acute respiratory failure. Once pain is managed, the client will be better able to engage in other respiratory interventions

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The nurse is caring for a client with respiratory failure. The client is lethargic and slow to follow commands. Current vital signs are: BP 88/52, pulse 132, respirations 8, and SPO2 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?

Nursing Test Bank

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Explanation

Correct Answer is D

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