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