The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings should the nurse identify as signs that the client has progressed to respiratory failure? Select all that apply.
A)Retractions and fatigue
B)Tachycardia and tachypnea
C)Inaudible breath sounds
D)Diffuse wheezing and the use of accessory muscles when inhaling
E)Reduced wheezing and an ineffective cough

Question

Quizplus · Accepted Answer

A)Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.
B)Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.
C)Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.
D)Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.
E)Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.

The Nurse Is Providing Care to a Client Admitted After