Nurse Moose
    Med Surg 2 Proctored ExamQuestion 71
    71 / 78
    Med surg 2 proctored exam

    Case study 71-73 A client was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear secretions. The previous shift nurse reports that the client had a very restless night with a drop in O2 saturation level several times despite O2 being set at 40% via trach collar. The previous shift nurse also reports that the client experienced tachycardia and tachypnea during the night. The nurse immediately checks on the client and finds that she appears anxious with these vital signs: Blood pressure: 130/90 mm Hg Heart rate: 116 (sinus tachycardia) Respiratory rate: 24 and labored Temperature: 99.6° F (axillary) O2 saturation: 91% on 40% O2 via trach collar Which finding(s) requires nursing intervention? Select all that apply.