Respiratory Distress: Recognition And Priorities
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NCLEX-RN › Respiratory Distress: Recognition And Priorities
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?
Stimulate the client, open the airway with a head-tilt chin-lift or jaw-thrust as appropriate, and apply oxygen
Request an order for naloxone before attempting to improve ventilation
Document the sedation level and reassess in 15 minutes
Delegate to assistive personnel to obtain a capillary blood glucose
Explanation
This question tests the recognition and prioritization of respiratory distress in a postoperative client with opioid-induced hypoventilation. The priority framework used is the ABCs (airway, breathing, circulation), prioritizing airway opening. Stimulating the client, opening the airway, and applying oxygen is the highest priority because it immediately improves ventilation in sedation-related depression. Documenting (B), delegating glucose (C), and requesting naloxone first (D) delay basic airway management. In respiratory cases, prioritization focuses on low respiratory rate and SpO2, using non-pharmacologic interventions first. Decision-making emphasizes arousal and positioning before reversal agents. A transferable strategy is to use jaw-thrust for snoring respirations, increase oxygen, and monitor closely post-opioids.
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?
Prepare to administer an antihistamine after completing a full respiratory assessment
Delegate to assistive personnel to obtain a set of orthostatic vital signs
Administer intramuscular epinephrine immediately and initiate high-flow oxygen
Obtain consent for possible endotracheal intubation
Explanation
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 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?
Teach the client diaphragmatic breathing for long-term management
Position the client upright and titrate oxygen per protocol to improve oxygenation
Collect a sputum sample after the next coughing episode
Delegate to assistive personnel to obtain a meal tray to conserve the client’s energy
Explanation
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 24-year-old client with a history of asthma arrives to the emergency department with sudden shortness of breath after exposure to cigarette smoke; the client is speaking in 1–2 word phrases with audible wheezing, respiratory rate 34/min, heart rate 128/min, blood pressure 146/88 mm Hg, oxygen saturation 86% on room air, and use of accessory muscles. Which action should the nurse take FIRST for this client?
Request a prescription for intravenous corticosteroids before starting any treatments
Obtain a peak expiratory flow reading to determine severity of the exacerbation
Delegate placement of an intravenous catheter to unlicensed assistive personnel while you chart
Apply oxygen and initiate a short-acting bronchodilator via nebulizer per protocol
Explanation
This question tests recognition and prioritization of respiratory distress in acute asthma exacerbation. The priority framework is ABCs (Airway, Breathing, Circulation), focusing on immediate oxygenation and bronchodilation. Applying oxygen and initiating a short-acting bronchodilator via nebulizer (B) is the highest priority because the client has severe hypoxemia (86% saturation) and significant bronchospasm requiring immediate intervention. Obtaining peak flow (A) delays treatment when the client is in severe distress; requesting IV corticosteroids (C) is important but secondary to immediate bronchodilation; delegating IV placement (D) while the client is in severe distress violates priority care principles. In respiratory emergencies, the decision-making principle is to address oxygenation and ventilation immediately before diagnostic measures or secondary interventions. The transferable strategy is: when a client presents with severe respiratory distress and hypoxemia, immediately provide oxygen and bronchodilators while continuously monitoring response.
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?
Place the client in high-Fowler position and start low-flow oxygen via nasal cannula
Collect a sputum specimen for culture before initiating any therapy
Teach diaphragmatic breathing techniques and energy conservation strategies
Encourage increased oral fluid intake to thin secretions
Explanation
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 28-year-old client with asthma presents with severe shortness of breath after running outside in cold air. Respiratory rate is 40/min, heart rate is 136/min, blood pressure is 150/90 mm Hg, oxygen saturation is 87% on room air, and wheezing is loud throughout all lung fields. Which action should the nurse take FIRST?
Administer a short-acting bronchodilator via nebulizer or metered-dose inhaler with spacer
Obtain a sputum culture and sensitivity specimen
Delegate to assistive personnel to set up a cool-mist humidifier
Teach the client to avoid exercise in cold environments
Explanation
This question tests the recognition and prioritization of respiratory distress in a client with exercise-induced asthma. The priority framework used is the ABCs (airway, breathing, circulation), focusing on relieving bronchospasm. Administering a short-acting bronchodilator is the highest priority because it rapidly opens airways and improves ventilation in severe wheezing and hypoxemia. Obtaining sputum (B), setting up humidifier (C), and teaching (D) are secondary to acute relief. In respiratory cases, prioritization targets wheezing and high respiratory rate, using medications before diagnostics. Decision-making principles stress immediate bronchodilation to prevent escalation. A transferable strategy is to assess triggers and wheezing, administer rescue inhalers promptly, and monitor response with SpO2.
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?
Obtain a complete respiratory history including prior intubations and hospitalizations
Administer a prescribed inhaled corticosteroid and evaluate response in 30 minutes
Position the client upright and administer oxygen while preparing to give a short-acting bronchodilator
Teach the client how to avoid triggers and develop an asthma action plan
Explanation
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 58-year-old client is 12 hours post-operative after abdominal surgery and has been receiving opioid analgesia; the client is difficult to arouse, respirations are shallow at 8/min, heart rate 96/min, blood pressure 118/70 mm Hg, and oxygen saturation is 82% on 2 L/min nasal cannula. Which action should the nurse take FIRST for this client?
Obtain an arterial blood gas sample to evaluate ventilation status
Increase the oxygen flow rate and reassess oxygen saturation in 10 minutes
Document the sedation level and notify the healthcare provider after completing vital signs
Stimulate the client, ensure airway patency, and apply a nonrebreather mask while calling for assistance
Explanation
This question tests recognition and prioritization of opioid-induced respiratory depression. The priority framework is ABCs with emphasis on immediate airway and breathing interventions. Stimulating the client, ensuring airway patency, and applying high-flow oxygen while calling for assistance (B) is the highest priority because the client has severe respiratory depression (8/min) and hypoxemia requiring immediate intervention and potential naloxone administration. Simply increasing oxygen (A) doesn't address the underlying hypoventilation; obtaining ABGs (C) delays urgent treatment; documenting before intervening (D) violates priority care principles. The decision-making principle is that respiratory rates below 10/min with altered consciousness constitute a medical emergency requiring immediate intervention. The transferable strategy is: when encountering opioid-induced respiratory depression, immediately stimulate the client, support ventilation, prepare naloxone, and activate emergency response.
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?
Start an intravenous line and wait for the healthcare provider to evaluate the client
Administer oral diphenhydramine and reassess airway swelling
Administer intramuscular epinephrine immediately and call the rapid response team
Obtain a detailed history of allergen exposure and previous reactions
Explanation
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 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?
Increase oxygen delivery and raise the head of the bed while staying with the client
Ask the client to rate pain and administer prescribed opioid analgesic
Request an order for a chest x-ray before changing oxygen therapy
Assess the surgical incision and measure drainage output
Explanation
This question tests the recognition and prioritization of respiratory distress in a postoperative client possibly experiencing a complication like pulmonary embolism. The priority framework used is the ABCs (airway, breathing, circulation), focusing on immediate oxygenation and client safety. Increasing oxygen delivery and raising the head of the bed while staying with the client is the highest priority because it improves ventilation-perfusion matching and monitors for deterioration in this unstable situation. Requesting a chest x-ray (B) delays care; assessing the incision (C) addresses surgical site but not breathing; and pain management (D) is important but secondary to hypoxemia. In respiratory cases, prioritization involves recognizing sudden onset symptoms like tachycardia and low SpO2, intervening to support breathing immediately. Decision-making emphasizes stabilizing the client before diagnostics, as delays can worsen outcomes in potential emboli or atelectasis. A transferable strategy is to elevate the head of the bed and titrate oxygen while continuously assessing mental status and calling for rapid response if distress persists.