- A 67-year-old client is 12 hours post-operative from abdominal surgery and reports sudden shortness of breath and anxiety. Respiratory rate is 30/min, heart rate is 118/min, blood pressure is 96/58 mm Hg, oxygen saturation is 84% on 2 L/min nasal cannula, and breath sounds are diminished at the bases. What is the PRIORITY nursing intervention for this client with respiratory distress?
Answer: Increase oxygen delivery and raise the head of the bed while staying with the client
An oxygen saturation of 84% with tachypnea, tachycardia, and hypotension indicates acute hypoxemia. The immediate priority is to support oxygenation: increase oxygen delivery and raise the head of the bed while staying with the client. This directly treats the threat to breathing and keeps the nurse at the bedside to detect deterioration. A portable chest x-ray may help identify the cause, but placing it before changing the current oxygen therapy delays a life-saving intervention in a critically hypoxemic client. Asking the client to rate pain and administering a prescribed opioid for surgical pain prioritizes a lower concern and can depress respirations. Assessing the surgical incision for bleeding and measuring wound drain output addresses a postoperative concern but does not treat the immediate respiratory distress. During acute hypoxemia, the ABCs come first: deliver oxygen, improve ventilation with positioning, and stay with the client.
- A 35-year-old client with a known peanut allergy ate a cookie at a party and now has hoarseness, lip and tongue swelling, diffuse hives, and severe shortness of breath; vital signs are respiratory rate 30/min with stridor, heart rate 132/min, blood pressure 86/54 mm Hg, and oxygen saturation 88% on room air. Which action should the nurse take FIRST?
Answer: Administer intramuscular epinephrine immediately and call the rapid response team
This question tests recognition and prioritization of anaphylactic respiratory distress. The priority framework is immediate life-saving intervention for anaphylaxis. Administering intramuscular epinephrine immediately (A) is the highest priority because the client has signs of anaphylaxis with airway compromise (stridor, swelling) and cardiovascular collapse (hypotension) requiring immediate epinephrine. Oral diphenhydramine (B) is too slow and inadequate for severe anaphylaxis; starting an IV and waiting (C) delays critical treatment; obtaining history (D) is inappropriate during a life-threatening emergency. The decision-making principle is that anaphylaxis with respiratory and cardiovascular compromise requires immediate epinephrine as the only effective first-line treatment. The transferable strategy is: when recognizing anaphylaxis with respiratory distress, administer epinephrine immediately without delay, as it is the only medication that reverses airway edema and cardiovascular collapse.
- A 40-year-old client develops respiratory distress and urticaria shortly after a latex exposure. Respiratory rate is 34/min, heart rate is 130/min, blood pressure is 88/52 mm Hg, oxygen saturation is 87% on room air, and inspiratory stridor is present. Which action should the nurse take FIRST?
Answer: Remove the latex source, administer intramuscular epinephrine, and apply high-flow oxygen
This question tests the recognition and prioritization of respiratory distress in a client with latex anaphylaxis. The priority framework used is the ABCs (airway, breathing, circulation), prioritizing removal and reversal. Removing the latex source, administering intramuscular epinephrine, and applying high-flow oxygen is the highest priority because it halts exposure and treats stridor. Applying cream (B), obtaining allergies (C), and delegating calls (D) delay. In respiratory cases, prioritization targets stridor with immediate epi. Decision-making stresses source removal first. A transferable strategy is to eliminate allergens, give epi, and oxygenate quickly.
- A 70-year-old client is 8 hours post-operative after thoracic surgery and suddenly has increased work of breathing. Respiratory rate is 32/min, heart rate is 116/min, blood pressure is 100/60 mm Hg, oxygen saturation is 83% on 4 L/min nasal cannula, and the client is anxious with cyanosis around the lips. Which action should the nurse take FIRST?
Answer: Apply a higher-concentration oxygen delivery device and assess airway patency while calling for assistance
This question tests the recognition and prioritization of respiratory distress in a postoperative thoracic surgery client. The priority framework used is the ABCs (airway, breathing, circulation), focusing on airway and oxygenation. Applying a higher-concentration oxygen device and assessing airway patency while calling for assistance is the highest priority because it addresses cyanosis and low SpO2 urgently. Notifying after assessment (B), delegating labs (C), and encouraging spirometry (D) are not first. In respiratory cases, prioritization recognizes cyanosis as critical, escalating oxygen. Decision-making principles prioritize calling help during intervention. A transferable strategy is to switch to nonrebreather and assess patency in postoperative distress.
- A 24-year-old client with asthma comes to the clinic with worsening shortness of breath and wheezing despite using a rescue inhaler at home. Respiratory rate is 30/min, heart rate is 120/min, blood pressure is 136/84 mm Hg, oxygen saturation is 90% on room air, and the client is speaking in short phrases. What is the PRIORITY nursing intervention?
Answer: Administer a short-acting bronchodilator and apply supplemental oxygen as needed
The ABCs decide this item: a respiratory rate of 30, heart rate of 120, SpO2 of 90 percent on room air, speech limited to short phrases, and wheezing that has not responded to home rescue therapy all describe active bronchospasm with impaired oxygenation. Administering a short-acting bronchodilator with supplemental oxygen as needed treats the breathing problem directly, and this is one of the situations where intervention precedes further data-gathering because the assessment findings that establish the emergency are already in the stem. Obtaining a detailed home medication list is useful history but does nothing to relieve bronchospasm in a client who can barely finish a sentence, and gathering history while oxygenation is falling is the classic assess-instead-of-act error. Teaching peak flow monitoring every morning is appropriate self-management education for a stable client, not a distressed one; a client speaking in short phrases cannot learn or perform it now. Delegating comfort items such as water and tissues to assistive personnel neither addresses breathing nor uses the assistant appropriately in an acute event. When the stem asks for the priority and an available action relieves airway obstruction or improves oxygenation, that outranks history-taking, teaching, and comfort measures every time.
- A 76-year-old client with COPD reports worsening dyspnea and is unable to finish sentences. Respiratory rate is 32/min, heart rate is 112/min, blood pressure is 158/92 mm Hg, oxygen saturation is 84% on 2 L/min nasal cannula, and the client is sitting upright in a tripod position. Which action should the nurse take FIRST?
Answer: Increase oxygen as prescribed using a Venturi mask and encourage pursed-lip breathing
In acute respiratory distress, the priority is oxygenation. This client cannot finish sentences, has a respiratory rate of 32, and is hypoxemic at 84% despite 2 L/min, so the nurse must act on the breathing problem first. Increasing oxygen as prescribed with a Venturi mask provides a precise, controlled FiO2, which is important in COPD, and pursed-lip breathing helps slow expiration and reduce air trapping. Obtaining a smoking pack-year history and baseline activity tolerance for pulmonary rehabilitation is a legitimate later plan, but it does not correct the immediate hypoxemia and is not the priority. Delegating to assistive personnel to ambulate the client and use incentive spirometry would increase oxygen demand in a client who cannot speak in full sentences; this is unsafe and not appropriate. Teaching about pneumococcal vaccination and annual influenza prevention is preventive care that should be done when the client is stable, not during acute distress. The tripod position and vital signs already show severe work of breathing, so stabilization of oxygenation comes before history, mobility, or teaching.
- A 58-year-old client with COPD exacerbation is receiving nebulized bronchodilators and reports increasing shortness of breath. Respiratory rate is 30/min, heart rate is 118/min, blood pressure is 146/82 mm Hg, oxygen saturation is 85% on 2 L/min nasal cannula, and the client is using accessory muscles. Which action should the nurse take FIRST?
Answer: Position the client upright and titrate oxygen per protocol to improve oxygenation
This question tests the recognition and prioritization of respiratory distress in a client with COPD exacerbation despite treatment. The priority framework used is the ABCs (airway, breathing, circulation), emphasizing oxygenation. Positioning upright and titrating oxygen per protocol is the highest priority because it enhances ventilation and corrects hypoxemia in accessory muscle use. Delegating meal (B), collecting sputum (C), and teaching (D) are secondary. In respiratory cases, prioritization addresses persistent low SpO2 post-nebs with supportive measures. Decision-making principles stress reassessment and adjustment after initial therapy. A transferable strategy is to titrate oxygen based on protocol and monitor work of breathing.
- A 63-year-old client is 24 hours post-operative after bowel resection and suddenly becomes confused and dyspneic. Respiratory rate is 26/min, heart rate is 120/min, blood pressure is 110/64 mm Hg, oxygen saturation is 85% on room air, and breath sounds are crackles at the bases. What is the PRIORITY nursing intervention for this client?
Answer: Apply oxygen and position the client upright, then reassess oxygen saturation and work of breathing
This question tests the recognition and prioritization of respiratory distress in a postoperative client with possible pulmonary edema or embolism. The priority framework used is the ABCs (airway, breathing, circulation), focusing on oxygenation. Applying oxygen and positioning upright, then reassessing is the highest priority because it improves gas exchange and monitors response in confusion and crackles. Requesting diuretic first (B), delegating weights (C), and assessing bowels (D) delay breathing support. In respiratory cases, prioritization targets confusion as a hypoxemia sign, intervening immediately. Decision-making principles prioritize oxygen over medications or assessments. A transferable strategy is to position upright and oxygenate while evaluating for fluid overload.
- A 69-year-old client with COPD is admitted for an exacerbation and is now increasingly somnolent. Respiratory rate is 10/min and shallow, heart rate is 96/min, blood pressure is 148/88 mm Hg, oxygen saturation is 92% on 4 L/min nasal cannula, and breath sounds are diminished. What is the PRIORITY nursing intervention?
Answer: Decrease oxygen flow to the lowest level that maintains the prescribed saturation and assess ventilation.
Ventilation is the immediate threat. This COPD client is somnolent, breathing shallowly at 10 breaths/min, and maintaining 92% saturation on supplemental oxygen—a pattern suggesting carbon dioxide retention and possible oxygen-induced hypoventilation. The priority is to reduce the oxygen flow to the lowest level that still maintains the prescribed saturation and then assess respiratory rate, depth, and mental status. Delegating oral hygiene, even with a reassessment afterward, is a comfort measure that can wait; it does not correct the dangerous respiratory pattern. Encouraging fluids to clear secretions is not the issue here and can be unsafe if the client is too drowsy to swallow. Teaching pursed-lip breathing is a later strategy; it requires alert cooperation and does not address the current hypoventil event. The choice that directly addresses the most life-threatening problem is the oxygen titration with ventilation assessment.
- A 71-year-old client with chronic obstructive pulmonary disease (COPD) reports increased dyspnea and a productive cough for 2 days. Respiratory rate is 28/min, heart rate is 110/min, blood pressure is 150/84 mm Hg, oxygen saturation is 86% on the client's home oxygen at 2 L/min nasal cannula, and breath sounds reveal diffuse wheezes with prolonged expiration. Which action should the nurse take FIRST?
Answer: Apply controlled oxygen therapy and place the client upright to improve ventilation
The client's oxygen saturation is 86% on 2 L/min home oxygen with tachypnea, tachycardia, and wheezing—airway and breathing are compromised right now. The first priority is to improve oxygenation and ventilation. Applying controlled oxygen and placing the client upright directly targets hypoxemia; controlled matters in COPD because oxygen should be titrated to avoid suppressing respiratory drive. Re-auscultating after 10 minutes of rest only repeats an assessment of a problem already documented and delays the needed intervention. Encouraging oral fluids and teaching huff coughing are useful for clearing secretions, but they are teaching and supportive measures, not an immediate response to low oxygen saturation. Delegating sputum collection to assistive personnel gathers diagnostic information that will not raise the saturation or improve air movement. When the question asks what to do first, an intervention that addresses a failing airway or breathing outranks further assessment, teaching, and diagnostics.
- A 72-year-old client with severe COPD is admitted for an exacerbation with increased dyspnea and cough; the client is somnolent, has a respiratory rate 6/min, shallow respirations, oxygen saturation 90% on 2 L/min nasal cannula, heart rate 92/min, and blood pressure 124/76 mm Hg. The nurse should QUESTION which order given the client's respiratory status?
Answer: Give morphine sulfate intravenously for dyspnea and anxiety
This question tests recognition of contraindicated interventions in respiratory depression. The priority framework is medication safety in respiratory compromise. The nurse should question giving morphine sulfate (B) because the client already has severe respiratory depression (rate 6/min) and altered consciousness (somnolent), and opioids would further suppress respiratory drive potentially causing respiratory arrest. Bronchodilators (A) may help COPD symptoms; ABGs (C) provide useful information; positioning and breathing techniques (D) are appropriate interventions. The decision-making principle is that respiratory depressants are contraindicated when respiratory rate is critically low, regardless of the indication. The transferable strategy is: always assess respiratory status before administering medications that depress respiratory drive, and question orders that could worsen existing respiratory depression.
- A 45-year-old client with a shellfish allergy develops wheezing, tongue swelling, and difficulty swallowing after eating at a restaurant. Respiratory rate is 34/min, heart rate is 128/min, blood pressure is 92/56 mm Hg, and oxygen saturation is 89% on room air. Which action should the nurse take FIRST?
Answer: Administer intramuscular epinephrine immediately and initiate high-flow oxygen
This question tests the recognition and prioritization of respiratory distress in a client with anaphylaxis. The priority framework used is the ABCs (airway, breathing, circulation), prioritizing reversal and support. Administering intramuscular epinephrine immediately and initiating high-flow oxygen is the highest priority because it treats swelling and hypoxemia rapidly. Preparing antihistamine (A), delegating vitals (C), and obtaining consent (D) delay critical actions. In respiratory cases, prioritization targets tongue swelling with epi and oxygen first. Decision-making emphasizes speed to prevent airway closure. A transferable strategy is to administer epi and oxygen in swelling, preparing for advanced airway.
- A 73-year-old client with COPD is admitted with increased dyspnea and is receiving oxygen at 2 L/min nasal cannula. Current status: respiratory rate 26/min, heart rate 104/min, blood pressure 140/78 mm Hg, oxygen saturation 88%, and the client is anxious and using accessory muscles. Which action should the nurse take FIRST?
Answer: Coach pursed-lip breathing and ensure the client is upright while assessing response to oxygen
Prioritize by the ABCs: a respiratory rate of 26, oxygen saturation of 88 percent, accessory muscle use, and anxiety all point to breathing as the active problem, so the first action must target ventilation. Coaching pursed-lip breathing and positioning the client upright while assessing the response to the current oxygen does exactly that, because pursed-lip breathing prolongs exhalation, reduces air trapping, and eases the work of breathing in COPD, and the upright position maximizes diaphragmatic excursion. A dietary consult for caloric intake addresses a real long-term COPD concern but does nothing for the client's current distress. Teaching early signs of infection is health promotion that a breathless, anxious client cannot absorb, so it belongs after the exacerbation is stabilized. Delegating a bed bath to assistive personnel spends the client's limited respiratory reserve on comfort care while the distress goes untreated. When a stem asks what to do FIRST, choose the intervention that directly improves ventilation or oxygenation; teaching, nutrition, and comfort measures always come after breathing is stabilized.
- A 61-year-old client develops sudden respiratory distress 4 hours after surgery. Respiratory rate is 28/min, heart rate is 120/min, blood pressure is 98/62 mm Hg, oxygen saturation is 85% on 2 L/min nasal cannula, and the client is anxious with nasal flaring. Which action should the nurse take FIRST?
Answer: Stay with the client, elevate the head of the bed, apply higher-flow oxygen, and call rapid response
The correct first action is to stay with the client, elevate the head of the bed, give higher-flow oxygen, and call the rapid response team. This client has tachypnea, tachycardia, hypotension, hypoxemia, and nasal flaring—all signs of acute respiratory decompensation. Positioning and increased oxygen improve gas exchange immediately, and calling rapid response brings additional help while keeping the nurse at the bedside. Completing the postoperative checklist and verifying intake and output totals is documentation, not treatment; it does not correct hypoxemia and wastes critical time. Delegating transport to radiology for a chest x-ray is unsafe because the client is unstable and must be stabilized and monitored before any diagnostic transport. Requesting a short-acting sedative for anxiety-related hyperventilation is harmful: the anxiety is a symptom of hypoxia, and a sedative can suppress respiratory drive and worsen respiratory failure. Use the ABC framework: secure airway, support breathing, and summon help before routine tasks or diagnostic tests.
- A 22-year-old client with a history of asthma arrives to the emergency department with audible wheezing and difficulty speaking in full sentences after exposure to cigarette smoke. Respiratory rate is 34/min, heart rate is 128/min, blood pressure is 142/86 mm Hg, oxygen saturation is 88% on room air, and the client is using accessory muscles with intercostal retractions. Which action should the nurse take FIRST for this client?
Answer: Place the client in high-Fowler's position and apply oxygen via nonrebreather mask
This is a classic ABCs item: audible wheezing, inability to speak in full sentences, accessory muscle use with retractions, and an oxygen saturation of 88% describe severe respiratory compromise, and breathing takes priority over every other action. Placing the client in high-Fowler's position and applying oxygen via nonrebreather mask is correct because upright positioning maximizes lung expansion and diaphragmatic excursion while high-flow oxygen corrects the hypoxemia immediately, buying time for bronchodilator therapy. Obtaining a peak expiratory flow measurement is a diagnostic maneuver that requires a forced exhalation from a client who cannot complete a sentence, so it delays treatment and adds work of breathing. Delegating serial vital signs to assistive personnel is appropriate monitoring but does nothing to treat the hypoxemia, and monitoring is not treatment when the client is deteriorating. Teaching about triggers and inhaler technique is valuable once the exacerbation resolves but is useless to a client in acute distress who cannot absorb it. When a stem asks what to do FIRST and any option addresses airway or breathing, that outranks assessment, monitoring, and education every time.
- A 67-year-old client with chronic obstructive pulmonary disease (COPD) reports increased dyspnea and a productive cough for 2 days; assessment shows pursed-lip breathing, diminished breath sounds with expiratory wheezes, respiratory rate 28/min, heart rate 110/min, blood pressure 138/84 mm Hg, temperature 38.1°C (100.6°F), and oxygen saturation 84% on room air. What is the PRIORITY nursing intervention for this client with respiratory distress?
Answer: Place the client in high-Fowler position and start low-flow oxygen via nasal cannula
This question tests recognition and prioritization of respiratory distress in COPD exacerbation. The priority framework is ABCs, focusing on immediate oxygenation needs. Placing the client in high-Fowler position and starting low-flow oxygen (A) is the highest priority because the client has significant hypoxemia (84% saturation) and increased work of breathing that requires immediate intervention. Encouraging fluid intake (B) is helpful but not the immediate priority; collecting sputum (C) delays urgent treatment; teaching breathing techniques (D) is inappropriate during acute distress. The decision-making principle in COPD exacerbations is to provide controlled oxygen therapy (avoiding high-flow oxygen that could suppress respiratory drive) while positioning to optimize ventilation. The transferable strategy is: for COPD clients in respiratory distress, immediately position upright and provide low-flow oxygen while monitoring for CO2 retention.
- A 66-year-old client with COPD is admitted for an exacerbation and is using accessory muscles with labored breathing; vital signs are respiratory rate 30/min, heart rate 108/min, blood pressure 136/80 mm Hg, temperature 37.9°C (100.2°F), and oxygen saturation 85% on room air; the client is alert but anxious and states, "I can't catch my breath." Which action should the nurse take FIRST?
Answer: Place the client in high-Fowler position and initiate low-flow oxygen therapy per protocol
This question tests recognition and prioritization of COPD exacerbation with respiratory distress. The priority framework is ABCs with focus on immediate oxygenation and positioning. Placing the client in high-Fowler position and initiating low-flow oxygen (B) is the highest priority because the client has significant hypoxemia (85%) and increased work of breathing requiring immediate intervention to improve oxygenation and reduce respiratory effort. Delegating I&O (A) abandons the client during acute distress; obtaining history (C) delays urgent treatment; encouraging coughing without addressing hypoxemia (D) is insufficient. The decision-making principle is to immediately address hypoxemia and optimize positioning in COPD exacerbations while using controlled oxygen delivery. The transferable strategy is: for COPD clients in acute distress, immediately position upright for optimal lung expansion and provide controlled oxygen therapy while closely monitoring response.
- A 41-year-old client with asthma presents with severe wheezing and dyspnea; vital signs are respiratory rate 36/min, heart rate 126/min, blood pressure 142/86 mm Hg, oxygen saturation 87% on room air, and the client is sitting upright and unable to lie flat. What is the PRIORITY nursing intervention for a client with respiratory distress?
Answer: Position the client upright and administer oxygen while preparing to give a short-acting bronchodilator
This question tests recognition and prioritization of severe asthma exacerbation. The priority framework is ABCs focusing on immediate oxygenation and bronchodilation. Positioning upright and administering oxygen while preparing bronchodilators (B) is the highest priority because the client has severe hypoxemia (87%) and respiratory distress requiring immediate intervention to improve oxygenation and prepare for bronchodilation. Inhaled corticosteroids (A) work too slowly for acute distress; teaching (C) is inappropriate during acute episodes; obtaining history (D) delays urgent treatment. The decision-making principle is to address hypoxemia immediately while preparing definitive bronchodilator therapy in severe asthma. The transferable strategy is: in acute asthma with hypoxemia, simultaneously provide oxygen and positioning while rapidly preparing short-acting bronchodilators for immediate administration.
- A 68-year-old client is 10 hours post-operative after colon surgery and suddenly complains of shortness of breath. Respiratory rate is 30/min, heart rate is 124/min, blood pressure is 92/60 mm Hg, oxygen saturation is 83% on 3 L/min nasal cannula, and the client is restless. Which assessment finding requires IMMEDIATE intervention?
Answer: Oxygen saturation of 83% despite supplemental oxygen with restlessness
This question tests the recognition and prioritization of respiratory distress in a postoperative client with possible complication. The priority framework used is the ABCs (airway, breathing, circulation), identifying hypoxemia. Oxygen saturation of 83% despite supplemental oxygen with restlessness requires immediate intervention because it indicates refractory hypoxemia and distress. Pain (B), constipation (C), and low fever (D) are common but secondary. In respiratory cases, prioritization focuses on persistent low SpO2 as critical. Decision-making emphasizes escalation for unrest. A transferable strategy is to reassess and increase oxygen in refractory cases.
- A 56-year-old client is 6 hours post-operative after a laparoscopic cholecystectomy and is receiving opioid analgesia. The client is difficult to arouse, has snoring respirations, respiratory rate 8/min, heart rate 88/min, blood pressure 118/72 mm Hg, and oxygen saturation 86% on 2 L/min nasal cannula. Which action should the nurse take FIRST?
Answer: Stimulate the client, open the airway with a head-tilt chin-lift or jaw-thrust as appropriate, and apply oxygen
This client shows opioid-induced respiratory depression: a rate of 8, oxygen saturation 86%, snoring respirations, and difficulty arousing. The immediate priority is airway and ventilation, so stimulating the client, opening the airway with a head-tilt chin-lift or jaw-thrust, and applying oxygen comes first. Requesting naloxone before improving ventilation delays the airway intervention and treats only one part of the problem; the airway must be opened and ventilation supported before considering a reversal agent. Delegating a capillary blood glucose check misses the emergency and is not the first action when breathing is compromised. Documenting and reassessing in 15 minutes is unsafe because waiting can allow further deterioration. The correct first action is the one that directly opens and supports the airway.
