Nclexrn Flashcards: Respiratory Distress Recognition And Priorities

What this deck covers

This deck focuses on Respiratory Distress Recognition And Priorities, giving you a quick way to review the definitions, rules, and examples that matter most for Nclexrn.

How to use these flashcards

Work through these flashcards in short sessions. Try to answer each prompt before flipping the card, then revisit any cards you miss until the explanation feels automatic.

Flashcard 1: Which device provides the highest FiO2 for a spontaneously breathing patient in acute distress?

Answer: Nonrebreather mask. Delivers near 100% oxygen with reservoir bag to maximize FiO2 in emergencies.

Flashcard 2: Which breath sound finding is most consistent with bronchospasm in asthma?

Answer: Wheezing. Results from air turbulence in narrowed lower airways due to smooth muscle constriction.

Flashcard 3: What is the priority nursing action for suspected aspiration with coughing and gurgling?

Answer: Suction the airway. Clears secretions or foreign material to restore airway patency and prevent further complications.

Flashcard 4: What does tachypnea most commonly indicate in early respiratory distress?

Answer: Compensatory response to hypoxemia or acidosis. Body increases respiratory rate to enhance gas exchange and correct blood gas imbalances.

Flashcard 5: Which assessment finding is the earliest sign of hypoxemia in most adults?

Answer: Restlessness or anxiety. Represents cerebral response to low oxygen levels before physical signs like cyanosis appear.

Flashcard 6: What is the priority positioning intervention to improve ventilation in respiratory distress?

Answer: High-Fowler position. Upright positioning optimizes lung expansion and reduces diaphragmatic pressure from abdominal contents.

Flashcard 7: What does a low SpO2 with normal respiratory rate most strongly suggest first?

Answer: Hypoxemia requiring oxygen and reassessment. Normal rate may mask underlying issues like shunt, necessitating oxygen to improve saturation.

Flashcard 8: Which action is priority when a tracheostomy tube becomes dislodged in a new tracheostomy?

Answer: Call for help and ventilate with bag-valve mask over stoma. New stoma requires expert reinsertion; BVM supports ventilation until help arrives.

Flashcard 9: What does a sudden absence of wheezing in a previously wheezing patient suggest?

Answer: Severe airflow obstruction (silent chest). Implies minimal air movement, escalating to respiratory failure without urgent treatment.

Flashcard 10: Which option is the most reliable indicator of oxygenation status at the bedside?

Answer: Pulse oximetry (SpO2) trend with clinical assessment. Combines non-invasive monitoring with symptoms for accurate, real-time evaluation of tissue oxygenation.

Flashcard 11: Which finding best indicates increased carbon dioxide retention (hypercapnia)?

Answer: Decreased level of consciousness. Hypercapnia causes CO2 narcosis, depressing central nervous system function.

Flashcard 12: Which breath sound finding suggests fluid in alveoli, such as pulmonary edema?

Answer: Crackles (rales). Produced by air bubbling through fluid-filled alveoli during inspiration.

Flashcard 13: Which assessment finding is a late sign of hypoxemia?

Answer: Cyanosis. Occurs when deoxyhemoglobin levels exceed 5 g/dL, indicating prolonged or severe oxygen desaturation.

Flashcard 14: What is the priority nursing action for suspected laryngospasm or severe stridor after extubation?

Answer: Provide oxygen and notify provider; prepare for reintubation. Supports oxygenation while alerting for potential airway securement to prevent complete obstruction.

Flashcard 15: Which breath sound finding indicates upper airway obstruction and is an emergency?

Answer: Stridor. High-pitched sound from turbulent airflow signals critical narrowing requiring immediate intervention.

Flashcard 16: What is the clinical meaning of accessory muscle use during breathing?

Answer: Increased work of breathing. Recruits additional muscles to overcome resistance or maintain adequate tidal volume.

Flashcard 17: What is the NCLEX priority nursing action when a patient shows signs of respiratory distress?

Answer: Assess airway and breathing; apply oxygen as indicated. Follows ABC priority in nursing to immediately address life-threatening compromise in oxygenation and ventilation.

Flashcard 18: Which oxygen delivery device is indicated when a precise FiO2 is required (for example, COPD)?

Answer: Venturi mask. Uses air entrainment to provide controlled, consistent oxygen concentration.

Flashcard 19: Which option is the priority intervention for a patient with suspected tension pneumothorax?

Answer: Prepare for emergent needle decompression. Relieves intrathoracic pressure to restore hemodynamics and ventilation urgently.

Flashcard 20: What is the primary goal of initial nursing interventions during respiratory distress?

Answer: Improve oxygenation and ventilation while preventing deterioration. Stabilizes gas exchange to avoid progression to failure or arrest.

Flashcard 21: Which option is the priority intervention for acute pulmonary edema with severe dyspnea?

Answer: High-Fowler and apply oxygen; prepare for positive-pressure support. Positioning and oxygen reduce work of breathing; PPV aids fluid redistribution and ventilation.

Flashcard 22: What is the priority action when a tracheostomy patient has acute respiratory distress?

Answer: Assess patency; suction and replace inner cannula if needed. Ensures tube functionality by removing obstructions and maintaining airway access.

Flashcard 23: Which breathing pattern suggests impending respiratory failure due to fatigue?

Answer: Bradypnea with decreasing tidal volume. Indicates respiratory muscle exhaustion, leading to inadequate ventilation and potential arrest.

Flashcard 24: What is the priority response when SpO2 is falling and the patient is becoming drowsy?

Answer: Activate rapid response; prepare for ventilatory support. Drowsiness signals worsening gas exchange, requiring team intervention to avoid respiratory arrest.

Flashcard 25: Which assessment finding is most consistent with tension pneumothorax?

Answer: Tracheal deviation away from the affected side. Pressure buildup shifts mediastinum, compressing great vessels and opposite lung.