When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

The patient's blood pressure is 164/98.

The patient appears somnolent.

The patient's oxygen saturation is 90%.

The patient reports feeling weak.

Answer and Explanation

The Correct Answer is B

B Somnolence, or excessive sleepiness, can indicate respiratory depression, hypercapnia (elevated PaCO2), or impending respiratory failure. Somnolence in this context is concerning as it may suggest worsening respiratory status and impending respiratory compromise. Therefore, it should be immediately reported to the healthcare provider for further evaluation and intervention.

A blood pressure of 164/98 mmHg is elevated but may not necessarily require immediate intervention, especially if the patient is not exhibiting signs of acute hypertensive crisis or end-organ damage.

However, it should be closely monitored and managed as appropriate. While hypertension may contribute to respiratory distress, it may not be the most critical finding to report immediately in a patient with possible respiratory failure and a high PaCO2.

C An oxygen saturation of 90% indicates hypoxemia, which can exacerbate respiratory failure and contribute to respiratory distress. While hypoxemia requires prompt intervention to improve oxygenation, it may not be the most critical finding to report immediately if the patient is not showing signs of severe respiratory distress or impending respiratory failure. However, it should be closely monitored and managed to prevent further deterioration.

D Weakness is a nonspecific symptom and may be related to various underlying causes, including respiratory failure, electrolyte imbalances, or systemic illness. While weakness warrants further assessment and management, it may not be the most urgent finding to report immediately in a patient with possible respiratory failure and a high PaCO2 unless it is accompanied by other concerning symptoms or signs of impending respiratory compromise.

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Correct Answer is B

Explanation

B. This is advised to prevent hypoxemia, which can manifest as tachycardia and arrhythmia, conditions indicated by an increased and irregular heart rate. Pre-oxygenation helps maintain adequate oxygen levels in the blood, which can be compromised during the suctioning process.

A. Obtaining a cardiology consult might be necessary if the client's heart rate increases and becomes irregular. However, it's not the immediate action the nurse should take. This option is more appropriate for addressing the underlying cause of the client's dysrhythmia rather than the immediate management during suctioning.

C. Suctioning the client less frequently might be appropriate if the client's response to suctioning is causing distress or physiological changes like increased heart rate. However, if suctioning is necessary due to secretions in the airway, simply reducing the frequency might not be sufficient to address the client's cardiovascular response.

D. Administering an antidysrhythmic medication should be considered if the client's heart rate increases and becomes irregular during or after suctioning, especially if the dysrhythmia persists or worsens.

However, this should be done under the guidance of a healthcare provider and after assessing the client's overall condition, including potential causes of the dysrhythmia.

A. Initiation of continuous positive pressure ventilation (CPAP) B. Endotracheal intubation and positive pressure ventilation C. Insertion of a mini-tracheostomy with frequent suctioning D. Administration of 100% 02 by non-rebreather mask

Correct Answer is B

Explanation

B. Endotracheal intubation and positive pressure ventilation are indicated in patients with severe respiratory failure who are unable to maintain adequate oxygenation and ventilation on their own. This intervention provides mechanical support to the patient's breathing by delivering positive pressure to the lungs via an endotracheal tube. Given the patient's respiratory rate of 6 breaths/min, low oxygen saturation (SpO2 of 78%), and increasing lethargy, endotracheal intubation and positive pressure ventilation are the most appropriate interventions to ensure adequate oxygenation and ventilation.

A. CPAP is a form of non-invasive positive pressure ventilation that helps keep the airways open and improves oxygenation. However, in a patient with severe respiratory failure and impending respiratory arrest, CPAP alone may not be sufficient to adequately support ventilation and oxygenation. CPAP is typically used in patients with milder forms of respiratory failure or as a step-down therapy from invasive mechanical ventilation.

C. Insertion of a mini-tracheostomy is not typically indicated in a patient with severe respiratory failure and impending respiratory arrest. While tracheostomy may be considered in certain cases for long-term ventilation or airway management, it is not the first-line intervention in an acute situation like this.

Additionally, frequent suctioning may not address the underlying cause of respiratory failure or improve oxygenation.

D. Administering 100% oxygen via a non-rebreather mask can help improve oxygenation temporarily. However, in a patient with severe respiratory failure and impending respiratory arrest, non-invasive oxygen therapy alone may not be sufficient to maintain adequate oxygenation and ventilation.

Endotracheal intubation and positive pressure ventilation are more definitive interventions to ensure adequate support for the patient's breathing.

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When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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