Respiratory Distress: Recognition And Priorities - NCLEX Rn
- Which device provides the highest FiO2 for a spontaneously breathing patient in acute distress?
- Nonrebreather mask. Delivers near 100% oxygen with reservoir bag to maximize FiO2 in emergencies.
- Which breath sound finding is most consistent with bronchospasm in asthma?
- Wheezing. Results from air turbulence in narrowed lower airways due to smooth muscle constriction.
- What is the priority nursing action for suspected aspiration with coughing and gurgling?
- Suction the airway. Clears secretions or foreign material to restore airway patency and prevent further complications.
- What does tachypnea most commonly indicate in early respiratory distress?
- Compensatory response to hypoxemia or acidosis. Body increases respiratory rate to enhance gas exchange and correct blood gas imbalances.
- Which assessment finding is the earliest sign of hypoxemia in most adults?
- Restlessness or anxiety. Represents cerebral response to low oxygen levels before physical signs like cyanosis appear.
- What is the priority positioning intervention to improve ventilation in respiratory distress?
- High-Fowler position. Upright positioning optimizes lung expansion and reduces diaphragmatic pressure from abdominal contents.
- What does a low SpO2 with normal respiratory rate most strongly suggest first?
- Hypoxemia requiring oxygen and reassessment. Normal rate may mask underlying issues like shunt, necessitating oxygen to improve saturation.
- Which action is priority when a tracheostomy tube becomes dislodged in a new tracheostomy?
- Call for help and ventilate with bag-valve mask over stoma. New stoma requires expert reinsertion; BVM supports ventilation until help arrives.
- What does a sudden absence of wheezing in a previously wheezing patient suggest?
- Severe airflow obstruction (silent chest). Implies minimal air movement, escalating to respiratory failure without urgent treatment.
- Which option is the most reliable indicator of oxygenation status at the bedside?
- Pulse oximetry (SpO2) trend with clinical assessment. Combines non-invasive monitoring with symptoms for accurate, real-time evaluation of tissue oxygenation.
- Which finding best indicates increased carbon dioxide retention (hypercapnia)?
- Decreased level of consciousness. Hypercapnia causes CO2 narcosis, depressing central nervous system function.
- Which breath sound finding suggests fluid in alveoli, such as pulmonary edema?
- Crackles (rales). Produced by air bubbling through fluid-filled alveoli during inspiration.
- Which assessment finding is a late sign of hypoxemia?
- Cyanosis. Occurs when deoxyhemoglobin levels exceed 5 g/dL, indicating prolonged or severe oxygen desaturation.
- What is the priority nursing action for suspected laryngospasm or severe stridor after extubation?
- Provide oxygen and notify provider; prepare for reintubation. Supports oxygenation while alerting for potential airway securement to prevent complete obstruction.
- Which breath sound finding indicates upper airway obstruction and is an emergency?
- Stridor. High-pitched sound from turbulent airflow signals critical narrowing requiring immediate intervention.
- What is the clinical meaning of accessory muscle use during breathing?
- Increased work of breathing. Recruits additional muscles to overcome resistance or maintain adequate tidal volume.
- What is the NCLEX priority nursing action when a patient shows signs of respiratory distress?
- Assess airway and breathing; apply oxygen as indicated. Follows ABC priority in nursing to immediately address life-threatening compromise in oxygenation and ventilation.
- Which oxygen delivery device is indicated when a precise FiO2 is required (for example, COPD)?
- Venturi mask. Uses air entrainment to provide controlled, consistent oxygen concentration.
- Which option is the priority intervention for a patient with suspected tension pneumothorax?
- Prepare for emergent needle decompression. Relieves intrathoracic pressure to restore hemodynamics and ventilation urgently.
- What is the primary goal of initial nursing interventions during respiratory distress?
- Improve oxygenation and ventilation while preventing deterioration. Stabilizes gas exchange to avoid progression to failure or arrest.
- Which option is the priority intervention for acute pulmonary edema with severe dyspnea?
- High-Fowler and apply oxygen; prepare for positive-pressure support. Positioning and oxygen reduce work of breathing; PPV aids fluid redistribution and ventilation.
- What is the priority action when a tracheostomy patient has acute respiratory distress?
- Assess patency; suction and replace inner cannula if needed. Ensures tube functionality by removing obstructions and maintaining airway access.
- Which breathing pattern suggests impending respiratory failure due to fatigue?
- Bradypnea with decreasing tidal volume. Indicates respiratory muscle exhaustion, leading to inadequate ventilation and potential arrest.
- What is the priority response when SpO2 is falling and the patient is becoming drowsy?
- Activate rapid response; prepare for ventilatory support. Drowsiness signals worsening gas exchange, requiring team intervention to avoid respiratory arrest.
- Which assessment finding is most consistent with tension pneumothorax?
- Tracheal deviation away from the affected side. Pressure buildup shifts mediastinum, compressing great vessels and opposite lung.