A client in respiratory failure exhibits agitation and restlessness. What is the most important goal for the nurse to focus on?

A client in respiratory failure exhibits agitation and restlessness. What is the most important goal for the nurse to focus on?

• A. Will have a heart rate of at least 110 bpm
• B. Will cough and deep breathe 10 times an hour
• C. Will have clear breath sounds in all lung areas
• D. Will have PaO2 of 90mmHg

Answer: (D)

In this scenario, the primary concern for a client experiencing respiratory failure is to ensure adequate oxygenation and ventilation. A target partial pressure of oxygen in arterial blood (PaO2) of 90 mmHg indicates that the client is receiving sufficient oxygen to meet the metabolic needs of the body. Achieving this goal is crucial, as hypoxia can lead to increased agitation and restlessness due to insufficient oxygen delivery to vital organs, including the brain. By focusing on maintaining a PaO2 at or above this level, the nurse can directly address the underlying issue related to respiratory failure. Other options, while relevant to overall patient care, do not directly prioritize the immediate need for adequate oxygenation. A heart rate above 110 bpm may indicate stress or tachycardia, but it is not a specific indicator of adequate oxygenation. Encouraging coughing and deep breathing can support lung function and clearance but may not address the immediate requirement for oxygen specifically in acute respiratory failure. Clear breath sounds are necessary for healthy lung function, but they do not quantify or confirm the patient's oxygen status. Thus, monitoring and achieving a PaO2 of 90 mmHg is the most appropriate goal in this context, as it directly correlates with improving the client's condition

In this scenario, the primary concern for a client experiencing respiratory failure is to ensure adequate oxygenation and ventilation. A target partial pressure of oxygen in arterial blood (PaO2) of 90 mmHg indicates that the client is receiving sufficient oxygen to meet the metabolic needs of the body.

Achieving this goal is crucial, as hypoxia can lead to increased agitation and restlessness due to insufficient oxygen delivery to vital organs, including the brain. By focusing on maintaining a PaO2 at or above this level, the nurse can directly address the underlying issue related to respiratory failure.

Other options, while relevant to overall patient care, do not directly prioritize the immediate need for adequate oxygenation. A heart rate above 110 bpm may indicate stress or tachycardia, but it is not a specific indicator of adequate oxygenation. Encouraging coughing and deep breathing can support lung function and clearance but may not address the immediate requirement for oxygen specifically in acute respiratory failure. Clear breath sounds are necessary for healthy lung function, but they do not quantify or confirm the patient's oxygen status. Thus, monitoring and achieving a PaO2 of 90 mmHg is the most appropriate goal in this context, as it directly correlates with improving the client's condition