Nursing Acceleration Challenge Exam (NACE) PN-RN Practice Test

What should a nurse monitor for if a patient has a respiratory rate of 8 per minute immediately after extubation?

1. Normal recovery.

2. Impaired oxygenation.

3. Stable respiratory function.

4. Need for further sedation.

The correct answer is: Impaired oxygenation.

In the context of a patient who has just been extubated, a respiratory rate of 8 breaths per minute is significantly lower than the expected normal range of 12 to 20 breaths per minute. Such a low respiratory rate indicates possible respiratory depression, which can lead to impaired oxygenation. Monitoring for impaired oxygenation is critical after extubation because the patient's ability to maintain adequate ventilation becomes more vulnerable as sedation from anesthesia or medications can linger in the system. A reduced respiratory rate can result in insufficient oxygen intake and increased carbon dioxide retention, which may manifest as hypoxia. Nurses need to assess the patient's oxygen saturation levels and look for signs of respiratory distress, such as changes in skin color, altered level of consciousness, or increased work of breathing. Prompt recognition of impaired oxygenation allows for timely interventions like supplemental oxygen or reintubation if necessary. Therefore, monitoring for impaired oxygenation is essential to ensure that the patient is recovering safely and effectively from the extubation process.