Nclexrn Quiz: Respiratory Distress Recognition And Priorities
20 questions · exam conditions
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Respiratory Distress Recognition And PrioritiesQuestion 1 of 20

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?

Administer intramuscular epinephrine immediately and initiate high-flow oxygen
Obtain consent for possible endotracheal intubation
Delegate to assistive personnel to obtain a set of orthostatic vital signs
Prepare to administer an antihistamine after completing a full respiratory assessment
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Nclexrn Quiz: Respiratory Distress Recognition And Priorities

Practice Respiratory Distress Recognition And Priorities in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Respiratory Distress Recognition And Priorities, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

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Question 1

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?

  1. Administer intramuscular epinephrine immediately and initiate high-flow oxygen (correct answer)
  2. Obtain consent for possible endotracheal intubation
  3. Delegate to assistive personnel to obtain a set of orthostatic vital signs
  4. Prepare to administer an antihistamine after completing a full respiratory assessment
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.

Question 2

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?

  1. Position the client upright and titrate oxygen per protocol to improve oxygenation (correct answer)
  2. Collect a sputum sample after the next coughing episode
  3. Teach the client diaphragmatic breathing for long-term management
  4. 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.

Question 3

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?

  1. Obtain a peak expiratory flow reading to determine severity of the exacerbation
  2. Apply oxygen and initiate a short-acting bronchodilator via nebulizer per protocol (correct answer)
  3. Request a prescription for intravenous corticosteroids before starting any treatments
  4. Delegate placement of an intravenous catheter to unlicensed assistive personnel while you chart
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.

Question 4

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?

  1. Place the client in high-Fowler position and start low-flow oxygen via nasal cannula (correct answer)
  2. Encourage increased oral fluid intake to thin secretions
  3. Collect a sputum specimen for culture before initiating any therapy
  4. Teach diaphragmatic breathing techniques and energy conservation strategies
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.

Question 5

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?

  1. Teach the client to avoid exercise in cold environments
  2. Administer a short-acting bronchodilator via nebulizer or metered-dose inhaler with spacer (correct answer)
  3. Obtain a sputum culture and sensitivity specimen
  4. Delegate to assistive personnel to set up a cool-mist humidifier
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.

Question 6

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?

  1. Administer a prescribed inhaled corticosteroid and evaluate response in 30 minutes
  2. Position the client upright and administer oxygen while preparing to give a short-acting bronchodilator (correct answer)
  3. Teach the client how to avoid triggers and develop an asthma action plan
  4. Obtain a complete respiratory history including prior intubations and hospitalizations
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.

Question 7

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?

  1. Administer intramuscular epinephrine immediately and call the rapid response team (correct answer)
  2. Administer oral diphenhydramine and reassess airway swelling
  3. Start an intravenous line and wait for the healthcare provider to evaluate the client
  4. 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.

Question 8

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?

  1. Obtain a detailed list of home medications and last doses taken
  2. Delegate to assistive personnel to provide water and tissues
  3. Teach the client to use a peak flow meter every morning
  4. Administer a short-acting bronchodilator and apply supplemental oxygen as needed (correct answer)
Explanation: 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.

Question 9

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?

  1. Obtain a dietary consult to increase caloric intake
  2. Teach the client how to recognize early signs of infection
  3. Coach pursed-lip breathing and ensure the client is upright while assessing response to oxygen (correct answer)
  4. Delegate to assistive personnel to assist with a bed bath to promote comfort
Explanation: 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.

Question 10

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?

  1. Request a portable chest x-ray to identify the cause before changing the current oxygen therapy
  2. Ask the client to rate pain and administer the prescribed opioid analgesic for surgical pain
  3. Increase oxygen delivery and raise the head of the bed while staying with the client (correct answer)
  4. Assess the surgical incision for bleeding and measure the drainage output from the wound drain
Explanation: 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.

Question 11

A 74-year-old client is 1 day post-operative after hip repair and becomes acutely short of breath while in bed. Respiratory rate is 28/min, heart rate is 122/min, blood pressure is 104/66 mm Hg, oxygen saturation is 82% on room air, and the client appears pale and diaphoretic. Which action should the nurse take FIRST?

  1. Assist the client to sit upright and apply oxygen, then notify the provider/rapid response team (correct answer)
  2. Delegate to assistive personnel to obtain a 12-lead electrocardiogram
  3. Perform incentive spirometry coaching for 10 breaths every hour
  4. Request an order for arterial blood gas analysis prior to oxygen administration
Explanation: This question tests the recognition and prioritization of respiratory distress in a postoperative client at risk for complications like fat embolism. The priority framework used is the ABCs (airway, breathing, circulation), emphasizing immediate support for breathing. Assisting the client to sit upright and applying oxygen, then notifying the provider or rapid response team is the highest priority because it addresses hypoxemia and facilitates breathing in acute distress. Incentive spirometry (B) is preventive; requesting ABG (C) delays oxygen; and delegating ECG (D) assesses heart but not first. In respiratory cases, prioritization focuses on low SpO2 and pallor, stabilizing with oxygen and positioning. Decision-making principles prioritize airway interventions over diagnostics in sudden onset. A transferable strategy is to position upright, provide oxygen, and call for help while reassessing work of breathing.

Question 12

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?

  1. Stimulate the client, open the airway with a head-tilt chin-lift or jaw-thrust as appropriate, and apply oxygen (correct answer)
  2. Request an order for naloxone from the provider before attempting to improve the client's ventilation with oxygen
  3. Delegate to assistive personnel to obtain a capillary blood glucose sample and report the result before further interventions
  4. Document the client's sedation level in the electronic record and reassess the respiratory status in 15 minutes
Explanation: 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.

Question 13

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?

  1. Stay with the client, elevate the head of the bed, apply higher-flow oxygen, and call rapid response (correct answer)
  2. Complete the post-operative checklist and verify intake and output totals from the electronic health record
  3. Delegate to assistive personnel to transport the client to radiology for a stat chest x-ray
  4. Request an order for a short-acting sedative to reduce anxiety-related hyperventilation and lower oxygen consumption
Explanation: 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.

Question 14

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?

  1. Increase the oxygen flow rate and reassess oxygen saturation in 10 minutes while observing for response
  2. Stimulate the client, ensure airway patency, and apply a nonrebreather mask while calling for assistance (correct answer)
  3. Obtain an arterial blood gas sample to evaluate ventilation status and check for carbon dioxide retention
  4. Document the client's sedation level and notify the healthcare provider after completing a second set of vital signs
Explanation: This client has opioid-induced respiratory depression with a suppressed level of consciousness, shallow respirations of 8/min, and oxygen saturation of 82%. This is an airway and breathing emergency. The first action is to stimulate the client, ensure the airway is open, deliver high-flow oxygen with a nonrebreather mask, and call for immediate assistance. Increasing oxygen flow and waiting for 10 minutes to reassess is too incomplete because it does not address poor ventilation or the need for help. Obtaining an arterial blood gas sample is a diagnostic action that delays immediate airway and breathing support. Documenting the sedation level and notifying the healthcare provider after another set of vital signs also delays the emergency response. The priority is to support airway and ventilation immediately while preparing for possible naloxone administration.

Question 15

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?

  1. Delegate to assistive personnel to obtain the client's morning laboratory results
  2. Apply a higher-concentration oxygen delivery device and assess airway patency while calling for assistance (correct answer)
  3. Encourage the client to use the incentive spirometer every hour while awake
  4. Notify the surgeon after completing a full head-to-toe assessment
Explanation: 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.

Question 16

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?

  1. Delegate to assistive personnel to perform oral hygiene and then reassess respiratory rate and oxygen saturation.
  2. Decrease oxygen flow to the lowest level that maintains the prescribed saturation and assess ventilation. (correct answer)
  3. Encourage the client to drink warm fluids at regular intervals to clear secretions and clear the airway.
  4. Provide teaching about pursed-lip breathing to reduce dyspnea when the client is alert and able to participate.
Explanation: 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.

Question 17

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?

  1. Remove the latex source, administer intramuscular epinephrine, and apply high-flow oxygen (correct answer)
  2. Delegate to assistive personnel to call the client's family member to update them
  3. Obtain a complete set of allergies and prior reactions before intervening
  4. Apply topical corticosteroid cream to areas of urticaria
Explanation: 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.

Question 18

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?

  1. Provide teaching on avoiding asthma triggers and proper inhaler technique
  2. Delegate to assistive personnel to obtain a full set of vital signs every 15 minutes
  3. Place the client in high-Fowler's position and apply oxygen via nonrebreather mask (correct answer)
  4. Obtain a peak expiratory flow measurement and document the result
Explanation: 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.

Question 19

A 28-year-old client with a history of anaphylaxis to shellfish ate at a restaurant and now has tightness in the throat, audible stridor, facial swelling, and wheezing; vital signs are respiratory rate 28/min, heart rate 118/min, blood pressure 92/58 mm Hg, and oxygen saturation 90% on room air. Which action should the nurse take FIRST?

  1. Administer nebulized albuterol to relieve wheezing
  2. Start a large-bore intravenous line and infuse normal saline rapidly
  3. Administer intramuscular epinephrine immediately (correct answer)
  4. Administer intravenous corticosteroids to prevent a biphasic reaction
Explanation: This question tests recognition and prioritization of anaphylaxis with respiratory compromise. The priority framework is immediate life-saving intervention for anaphylactic shock. Administering intramuscular epinephrine immediately (C) is the highest priority because the client has anaphylaxis with upper airway obstruction (stridor), lower airway involvement (wheezing), and cardiovascular compromise (hypotension) requiring immediate epinephrine as the only effective treatment. Albuterol (A) treats wheezing but not the underlying anaphylaxis; IV fluids (B) are supportive but secondary to epinephrine; corticosteroids (D) prevent late reactions but don't treat acute anaphylaxis. The decision-making principle is that epinephrine is the first-line and only immediately effective treatment for anaphylaxis. The transferable strategy is: when anaphylaxis presents with any combination of airway, breathing, or circulation compromise, administer epinephrine immediately without delay.

Question 20

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?

  1. Delegate measurement of intake and output to unlicensed assistive personnel while you stay with the client
  2. Place the client in high-Fowler position and initiate low-flow oxygen therapy per protocol (correct answer)
  3. Obtain a detailed smoking history and review home inhaler technique
  4. Encourage coughing and deep breathing and reassess lung sounds in 30 minutes
Explanation: 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.