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 D

Explanation

A. Similar to the angina attacks you had in the past:
This response is not entirely accurate. Angina refers to chest pain that occurs when the heart's demand for oxygen exceeds its supply, usually due to partial blockage of the coronary arteries. NSTEMI (non-ST elevation myocardial infarction) is different from angina in that it involves actual heart muscle injury or damage due to partial or intermittent blockage of a coronary artery, whereas angina does not cause permanent heart muscle damage. Therefore, describing NSTEMI as similar to past angina attacks would be misleading.

B. A condition characterized by coronary arteries vasodilating:
This is incorrect. NSTEMI occurs due to a partial blockage or narrowing of the coronary arteries, usually caused by a blood clot that forms around a ruptured atherosclerotic plaque. The blockage restricts blood flow to the heart muscle, causing injury or infarction. Vasodilation (the widening of blood vessels) is not a characteristic of NSTEMI; in fact, it is the constriction or blockage of the coronary arteries that leads to this type of heart attack.

C. A term used to describe an irregular heartbeat:
This is incorrect. NSTEMI is not related to an irregular heartbeat or arrhythmia directly. While arrhythmias (irregular heartbeats) can occur as a result of a heart attack, NSTEMI specifically refers to a type of heart attack that is not accompanied by the characteristic ST-segment elevation seen on an electrocardiogram (ECG) in a STEMI (ST-elevation myocardial infarction). It indicates a partial blockage of a coronary artery and is generally less severe than STEMI.

D. Is a less severe type of heart attack compared to STEMI:
This is the most accurate response. NSTEMI is a type of heart attack that is often considered less severe than STEMI, but still involves heart muscle injury. The difference between NSTEMI and STEMI lies in the ECG findings: STEMI involves a full-thickness myocardial infarction with a significant blockage of the artery, as indicated by ST-segment elevation on an ECG. In NSTEMI, there is a partial blockage or temporary decrease in blood flow, and the ST-segment does not elevate on the ECG, but biomarkers (like troponin) are elevated, indicating heart muscle damage. NSTEMI is often less severe in terms of the extent of damage compared to STEMI, but it still requires urgent treatment to prevent further complications.

A. pH 7.33, PaCO2 35 mmHg, Pa02 78 mmHg, HCO3 20 mEq/L. B. heart rate 80 and respiratory rate 20. C. 02 saturation of at least 94%. D. sodium 135 mg/di. and potassium 4.8 mg/dL.

Correct Answer is C

Explanation

A. pH 7.33, PaCO2 35 mmHg, PaO2 78 mmHg, HCO3 20 mEq/L:
This answer choice indicates respiratory acidosis (pH < 7.35, low bicarbonate), but the goal in acute respiratory failure is not just to adjust the pH alone; the more immediate concern is correcting oxygenation. The PaO2 of 78 mmHg is below the normal range (80-100 mmHg), indicating hypoxemia that should be corrected first. The goal should be to improve PaO2 to acceptable levels (≥80 mmHg) and achieve adequate oxygen saturation. This ABG result does not fully align with the immediate goals of treatment.

B. Heart rate 80 and respiratory rate 20:
While normal vital signs like heart rate and respiratory rate are important, they are not the primary goal of treatment in acute respiratory failure. The focus during ventilator support is to improve oxygenation and ventilation rather than simply achieving normal heart and respiratory rates. In acute respiratory failure, abnormal heart and respiratory rates are often a result of hypoxia or hypercapnia (high CO2), so normalizing oxygenation and carbon dioxide levels is more critical initially.

C. O2 saturation of at least 94%:
The primary goal in acute respiratory failure is to maintain adequate oxygenation. In this context, the goal of ventilator support is to correct hypoxemia (low blood oxygen levels) and restore normal oxygen saturation. A target oxygen saturation of at least 94% is commonly considered appropriate for most patients in acute respiratory failure to ensure that tissues are receiving enough oxygen to prevent organ damage. This is a key aspect of managing respiratory failure and ensuring adequate tissue perfusion. Oxygen saturation below 90% is typically considered to indicate a severe level of hypoxemia, requiring prompt intervention.

D. Sodium 135 mg/dL and potassium 4.8 mg/dL:
While electrolyte levels are important to monitor in any critically ill patient, the main goal of treatment in acute respiratory failure is improving oxygenation and ventilation rather than focusing specifically on normalizing sodium or potassium levels. Correcting imbalances in electrolytes can be part of overall care, but it is not the primary objective in this situation. Oxygenation (as measured by PaO2 and O2 saturation) takes priority over correcting individual electrolytes.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

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?

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Naxlex Comprehensive Predictor Exams

The client tells the nurse, "My physician told me that I had a non-ST elevation myocardial infarction (NSTEMI). " I thought all heart attacks were the same. Can you explain this to me?" The nurse's best response to the client's question would be: "NSTEMI is

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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