Respiratory questions appear throughout the NCLEX and require you to recognize deterioration early, know oxygen delivery systems, interpret ABGs, and intervene in the correct sequence.
Respiratory Assessment: What Matters Most
Priority respiratory assessment data
- SpO2: Target >95% (exception: COPD patients — see below)
- Respiratory rate: Normal 12–20/min. RR >30 = respiratory distress
- Work of breathing: Nasal flaring, tripod positioning, accessory muscle use, intercostal retractions
- Auscultation: Crackles (fluid), wheezes (bronchoconstriction), stridor (upper airway obstruction), absent breath sounds (pneumothorax or consolidation)
- Mental status change in a hypoxic patient = immediate intervention
COPD Nursing: The Oxygen Controversy
COPD patients with chronic CO2 retention (hypercapnic) rely on hypoxic drive to breathe. High-flow oxygen can suppress this drive and cause respiratory depression. This is the most tested COPD nursing concept on the NCLEX.
NCLEX rule for COPD oxygen delivery:
- Target SpO2: 88–92% for chronic COPD (not the usual 95–100%)
- Use Venturi mask — most precise oxygen delivery for COPD patients (delivers exact FiO2)
- Start at low flow (1–2 L/min nasal cannula) and titrate
- Monitor respiratory rate and CO2 level — if patient becomes drowsy or RR decreases, lower oxygen
Asthma: Acute Exacerbation Management
Mild-moderate exacerbation
- Position patient upright (high Fowler's)
- Oxygen titrated to SpO2 >92%
- Short-acting beta-2 agonist (albuterol) via MDI or nebulizer — priority bronchodilator
- Systemic corticosteroids if not rapidly improving
- Ipratropium bromide (anticholinergic) may be added for severe exacerbation
Status asthmaticus (life-threatening)
Severe asthma unresponsive to bronchodilators. Signs: inability to speak in full sentences, SpO2 <90% on O2, RR >30, "silent chest" (no wheezing = no air movement — most ominous sign). Action: immediate escalation, IV magnesium sulfate, possible intubation.
Teaching for MDI use: Shake, exhale completely, hold device 1–2 inches from mouth OR use spacer, inhale slowly over 3–5 seconds, hold breath 10 seconds, wait 1 minute between puffs. Rinse mouth after corticosteroid inhaler (prevents oral candidiasis).
Pneumonia: Nursing Assessment and Care
| Type | Common organisms | Nursing priority |
|---|---|---|
| Community-acquired | Strep pneumoniae (#1), Mycoplasma, Legionella | Respiratory isolation if TB suspected; deep breathing and coughing exercises; incentive spirometry |
| Hospital-acquired (HAP) | Gram-negatives (Pseudomonas, Klebsiella), MRSA | Strict hand hygiene; head of bed elevation (HOB 30–45°) to prevent VAP |
| Aspiration | Anaerobes, gram-negatives | Aspiration precautions: HOB >30°, check NG tube position, assess gag reflex |
Oxygen Delivery Systems: Choosing the Right Device
| Device | FiO2 range | Use when |
|---|---|---|
| Nasal cannula | 24–44% (1–6 L/min) | Mild hypoxia, patient comfort, chronic use |
| Simple face mask | 35–55% (6–10 L/min) | Moderate hypoxia; minimum 6 L/min to prevent CO2 rebreathing |
| Non-rebreather mask | 60–80% (10–15 L/min) | Severe hypoxia — keep reservoir bag inflated at all times; first-line for CO poisoning |
| Venturi mask | Precise 24–50% | COPD — most controlled delivery; preferred when exact FiO2 matters |
| BiPAP/CPAP | Variable with PEEP | Respiratory failure, sleep apnea, acute decompensated HF (pulmonary edema) |
Chest Tubes: Priority Nursing Care
Used for pneumothorax, hemothorax, pleural effusion. Key nursing responsibilities:
- Keep drainage system below chest level — always, to maintain water seal
- Tidaling is normal — water level should rise on inspiration, fall on expiration
- Continuous bubbling in water seal = air leak — notify provider (intermittent bubbling during coughing is normal initially)
- Never clamp a chest tube without a direct order — risk of tension pneumothorax
- If tube disconnects: immediately submerge end in sterile water (emergency water seal)
- If tube dislodges: cover site with petroleum gauze taped on three sides (flutter valve)
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