A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

Initiation of continuous positive pressure ventilation (CPAP)

Endotracheal intubation and positive pressure ventilation

Insertion of a mini-tracheostomy with frequent suctioning

Administration of 100% 02 by non-rebreather mask

Answer and Explanation

The Correct Answer is B

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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Correct Answer is B

Explanation

B. Checking the left hand for pallor can help assess peripheral perfusion and determine if there is adequate blood flow distal to the arterial line insertion site. Pallor in the left hand could indicate decreased perfusion, which may contribute to the low-pressure alarm.

A. Re-zeroing the monitoring equipment may be necessary to ensure accurate pressure readings. However, it should not be the first action taken when the low-pressure alarm sounds. Before re-zeroing, the nurse should assess the patient's condition to ensure there are no immediate issues affecting arterial pressure.

C. Fast flushing the arterial line is not typically the first action to take when the low-pressure alarm sounds. Fast flushing may increase the risk of dislodging the catheter or causing air embolism if there is a problem with the line.

D. Assessing for dysrhythmias should be part of the overall assessment but may not be the first action taken in response to the alarm.

A. Decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Decreased specific gravity D. Increased pulmonary artery wedge pressure (PAWP).

Correct Answer is B

Explanation

B. Right-sided heart failure leads to congestion of the systemic venous circulation, resulting in increased central venous pressure (CVP). Elevated CVP is a hallmark sign of right-sided heart failure and is often used clinically to assess right ventricular preload and volume status.

A. BNP is a hormone secreted by the heart in response to increased ventricular stretch and volume overload, and its levels are usually elevated in heart failure, including both left-sided and right-sided heart failure.

C. Specific gravity refers to the concentration of solutes in urine and is often used as a measure of urine concentration.

D. Pulmonary artery wedge pressure (PAWP) is a measure of left atrial pressure and left ventricular end- diastolic pressure. In right-sided heart failure, the primary hemodynamic abnormality is congestion of the systemic venous circulation, rather than elevated left-sided pressures.

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A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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