Progressive Care Nursing Certification (PCCN) Practice Exam

When assessing a patient with acute respiratory failure, which of the following should be included?

1. Vital signs only

2. Heart rate and rhythm

3. Mental status and work of breathing

4. Only oxygen saturations

The correct answer is: Mental status and work of breathing

In assessing a patient with acute respiratory failure, evaluating mental status and work of breathing is essential because both provide critical insights into the patient's respiratory function and overall stability. A change in mental status can indicate hypoxia or hypercapnia, both of which are common in respiratory failure. Additionally, assessing the work of breathing helps to identify respiratory distress, revealing if the patient is using accessory muscles, demonstrating tachypnea, or showing any signs of fatigue or discomfort. This comprehensive assessment helps to tailor interventions effectively to address the patient's needs. While vital signs, heart rate, rhythm, and oxygen saturation are important components of a complete assessment, they do not provide the full picture necessary to evaluate the complexities of respiratory failure. Moreover, just focusing on oxygen saturations can overlook critical indicators such as mental status changes and the physical effort required for breathing, which can significantly impact patient care and outcomes.