CNA Certification (Written Exam)Basic Nursing SkillsHard
A nurse aide is observing a resident who is receiving oxygen through a nasal cannula. Which observation would require the nurse aide to report to the nurse immediately?
- AThe resident's oxygen tubing is draped over their ear.
- BThe resident's skin around the nasal cannula is red and irritated.
- CThe resident's respiratory rate drops from 20 breaths/min to 10 breaths/min.
- DThe resident complains of dryness in their nose.
Show answer & explanationAnswer & explanation
Correct answer: C. The resident's respiratory rate drops from 20 breaths/min to 10 breaths/min.
A significant drop in respiratory rate (bradypnea) from 20 to 10 breaths/min, especially in someone receiving oxygen, can indicate over-sedation, respiratory depression, or other serious respiratory compromise. This is a critical change in a vital sign and requires immediate reporting to the nurse.
Why the other options are wrong
- A. Tubing over the ear can cause mild discomfort or skin breakdown, but is not an immediate life-threatening concern.
- B. Skin irritation is a concern for skin integrity and pressure injury, requiring intervention, but is not as immediately life-threatening as respiratory depression.
- D. Nasal dryness is a common side effect of oxygen therapy and can be addressed with humidification or saline, but is not an immediate emergency.
Respiratory Depression (Bradypnea)
A significant and sudden decrease in respiratory rate (bradypnea) is a critical sign of respiratory depression and requires immediate reporting to the nurse.
- Normal adult rate: 12-20 breaths/min.
- Bradypnea: <12 breaths/min.
- Can indicate over-sedation or respiratory failure.
- Always report immediately.
Memory trick: Breathing Down? Report Now!