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.

A. This value is slightly elevated but within a range that does not indicate immediate compromise. It may reflect anxiety or a mild stress response. B. Tachycardia in this context suggests physiologic stress and compensatory response to hypoxia, anxiety, or early respiratory compromise, requiring intervention and monitoring. C. A respiratory rate above 20 with labored breathing indicates increased work of breathing and potential respiratory distress, which requires immediate nursing assessment and intervention. D. This is a low-grade elevation and does not require immediate action in this context. It may reflect mild inflammation or recent activity, not an acute threat. E. Oxygen saturation below 92% on supplemental oxygen indicates inadequate oxygenation, which requires prompt intervention such as assessing airway patency, suctioning secretions, adjusting oxygen delivery, or notifying the healthcare provider.