NCLEX Medical-Surgical: Respiratory Conditions 1 — Questions and Answers

Question 1: A patient with COPD is admitted for exacerbation. Which oxygen delivery goal is most appropriate for this patient?

Maintain SpO2 at 99–100% to maximize oxygenation
Maintain SpO2 at 88–92% to avoid suppressing hypoxic respiratory drive (Correct answer)
Apply 100% non-rebreather mask immediately regardless of baseline
Withhold oxygen entirely to preserve the hypoxic drive

Correct answer: Maintain SpO2 at 88–92% to avoid suppressing hypoxic respiratory drive

COPD patients who are chronic CO2 retainers may rely on hypoxic drive (low O2) to breathe. Targeting SpO2 88–92% provides adequate oxygenation without suppressing respiratory drive or worsening hypercapnia.

Many COPD patients with chronic hypercapnia (CO2 retainers) have adapted their chemoreceptors to high CO2 levels and rely on hypoxemic drive (low O2) as the primary stimulus to breathe. Administering high-flow O2 can suppress this drive, leading to hypoventilation and worsening hypercapnia/respiratory acidosis. Current GOLD guidelines recommend targeting SpO2 88–92% in COPD exacerbations — adequate oxygenation without hyperoxia. Use controlled low-flow oxygen (1–2 L/min nasal cannula or Venturi mask). Monitor ABGs. Note: this applies specifically to CO2 retainers — the majority of COPD patients can tolerate normal SpO2 targets. Hypoxia is still more immediately dangerous than hyperoxia in most situations.

Question 2: A nurse is caring for a patient with a right-sided pneumothorax. On assessment, the nurse notes tracheal deviation to the left, absent breath sounds on the right, and severe respiratory distress. What condition does this represent?

Simple pneumothorax requiring observation
Tension pneumothorax requiring immediate needle decompression (Correct answer)
Pleural effusion requiring thoracentesis
Hemothorax requiring chest tube placement

Correct answer: Tension pneumothorax requiring immediate needle decompression

Tracheal deviation away from the affected side, absent breath sounds, and severe respiratory distress indicate tension pneumothorax — a life-threatening emergency requiring immediate needle decompression (2nd intercostal space, midclavicular line).

Tension pneumothorax occurs when air enters the pleural space through a one-way valve mechanism, continuously accumulating and unable to escape. The increasing pressure compresses the ipsilateral lung, shifts mediastinum to the contralateral side (tracheal deviation away from pneumothorax), compresses the contralateral lung, and kinks the vena cava — causing obstructive shock. Classic signs: severe dyspnea, absent breath sounds on affected side, tracheal deviation AWAY from affected side, hypotension, distended neck veins, tachycardia. Treatment: EMERGENCY needle decompression — 2nd intercostal space, midclavicular line, large-bore needle (14G) — immediately followed by chest tube thoracostomy. Do not wait for X-ray confirmation. A simple pneumothorax lacks hemodynamic instability and tracheal deviation.

Question 3: A patient is receiving mechanical ventilation and the nurse notes high-pressure alarms. Which assessment should the nurse perform first?

Increase the set tidal volume to overcome the obstruction
Assess the patient and ventilator circuit for obstruction — suctioning, kinking, patient biting tube, bronchospasm (Correct answer)
Immediately disconnect the patient from the ventilator
Increase FiO2 to compensate for potential hypoxia

Correct answer: Assess the patient and ventilator circuit for obstruction — suctioning, kinking, patient biting tube, bronchospasm

High-pressure alarms indicate increased resistance or obstruction in the circuit or patient airway. Assessment should identify and correct the cause — secretions, tube kinking, bronchospasm, or pneumothorax.

Ventilator alarm troubleshooting: High-pressure alarm (above the set pressure limit) indicates increased resistance. Causes: (1) Secretion accumulation (suction); (2) ETT kinking (reposition head, check bite block); (3) Patient coughing/biting the tube (bite block, sedation review); (4) Bronchospasm (bronchodilator); (5) Pneumothorax; (6) ETT displacement into right mainstem bronchus (pull back, confirm position by CXR); (7) ETT obstruction. Low-pressure/disconnect alarm: circuit disconnect, cuff leak (check cuff pressure 20–30 cmH2O). Critical rule: if the cause cannot be quickly identified and corrected, manually ventilate the patient with a bag-valve mask (BVM) while troubleshooting. Never leave the alarm sounding without acting. Notify the provider and respiratory therapist immediately for complex issues.

Question 4: A patient is admitted with community-acquired pneumonia (CAP). Which findings support this diagnosis?

Clear lung fields on chest X-ray, low-grade fever, and dry cough
Productive cough, fever, pleuritic chest pain, focal infiltrate on CXR, and elevated WBC (Correct answer)
Bilateral wheezing, expiratory prolongation, and low-grade fever
Sudden onset chest pain, dyspnea, and normal chest X-ray

Correct answer: Productive cough, fever, pleuritic chest pain, focal infiltrate on CXR, and elevated WBC

Community-acquired pneumonia presents with productive cough, fever, pleuritic chest pain, lobar or focal infiltrate on chest X-ray, and leukocytosis. Auscultation reveals bronchial breath sounds, crackles, and dullness to percussion over the affected area.

Community-acquired pneumonia (CAP) diagnosis requires: (1) Clinical findings: fever, chills, productive cough (purulent or rusty sputum), pleuritic chest pain, dyspnea, tachypnea, tachycardia; (2) Physical exam: dullness to percussion over consolidation, bronchial breath sounds (transmitted through solid lung), increased tactile fremitus, egophony (E → A sign), crackles; (3) Radiology: lobar or segmental infiltrate/consolidation on CXR or CT; (4) Labs: elevated WBC (>12,000) with left shift, elevated CRP/ESR, procalcitonin. Severity scoring: CURB-65 or PSI/PORT score guides hospitalization decision. Treatment: outpatient — amoxicillin ± macrolide; inpatient — beta-lactam + macrolide (or respiratory fluoroquinolone alone); ICU — antipseudomonal coverage.

Question 5: A patient is on continuous pulse oximetry. The SpO2 reads 97%, but the patient appears cyanotic, confused, and the waveform is poor. What action should the nurse take?

Trust the pulse oximetry reading and reassure the patient
Assess the patient clinically, obtain an ABG, and consider pulse ox inaccuracy (Correct answer)
Increase supplemental oxygen based on the 97% reading
Remove the pulse oximeter as it is clearly malfunctioning and not needed

Correct answer: Assess the patient clinically, obtain an ABG, and consider pulse ox inaccuracy

Pulse oximetry has limitations: poor perfusion, nail polish, carbon monoxide poisoning (falsely normal), methemoglobinemia, and motion artifact cause inaccurate readings. Clinical assessment and ABG are more reliable when clinical findings don't match.

Pulse oximetry limitations: (1) Carbon monoxide poisoning: SpHbCO reads as oxyhemoglobin — patient may be severely hypoxic despite SpO2 99%; (2) Methemoglobinemia: SpO2 approaches 85% regardless of actual oxygen saturation; (3) Poor peripheral perfusion (hypotension, cold extremities, vasoconstriction): unreliable readings, poor plethysmographic waveform; (4) Motion artifact; (5) Nail polish (especially dark colors or acrylics); (6) Severe anemia; (7) Jaundice. In this scenario: cyanosis (bluish discoloration) + confusion + poor waveform = clinical findings suggesting hypoxia. Action: clinical assessment, obtain ABG (measures actual PaO2, SaO2, and detects CO, methemoglobin with co-oximetry), address cause, improve perfusion if needed.

Question 6: A patient with pulmonary embolism (PE) is being anticoagulated with IV heparin. Which goal best describes anticoagulation in acute PE?

Dissolving the existing clot to restore pulmonary blood flow immediately
Preventing clot propagation and recurrence while allowing natural fibrinolysis (Correct answer)
Preventing DVT only — the PE itself resolves without treatment
Eliminating all risk factors for future emboli with a single medication

Correct answer: Preventing clot propagation and recurrence while allowing natural fibrinolysis

Heparin (and other anticoagulants) do not dissolve existing clots — they prevent new clot formation and propagation. The body's natural fibrinolytic system gradually dissolves the clot over weeks to months.

Mechanism of anticoagulants in PE: heparin/LMWH/DOACs do not dissolve existing clots — they prevent: (1) Propagation (extension) of the existing thrombus; (2) New clot formation; (3) Further embolization. Natural fibrinolysis (tPA system) gradually dissolves the embolus over 2–4 weeks. Thrombolytics (alteplase) DO dissolve clots and are reserved for massive PE with hemodynamic instability (hypotension, cardiac arrest). Anticoagulation duration: at least 3 months for provoked PE (surgery, immobility); indefinite for unprovoked PE or recurrent PE. Heparin bridging to warfarin (INR 2–3) or DOAC (rivaroxaban, apixaban). Monitor for bleeding. IVC filter for contraindication to anticoagulation.

Question 7: A nurse is caring for a patient following a bronchoscopy with biopsy. Which postprocedure complication requires immediate intervention?

Mild sore throat and hoarseness for 24 hours
Frank hemoptysis with large amounts of blood, worsening dyspnea, and hypoxia (Correct answer)
NPO status for 2 hours after the procedure
Mild productive cough for 12 hours after procedure

Correct answer: Frank hemoptysis with large amounts of blood, worsening dyspnea, and hypoxia

While minor hemoptysis and cough are expected after bronchoscopy with biopsy, frank significant hemoptysis with respiratory compromise indicates airway hemorrhage — a serious complication requiring immediate intervention.

Bronchoscopy complications: Common/expected: mild sore throat, hoarseness (from scope trauma), minor blood-tinged sputum for 24–48 hours, nausea from sedation, transient bronchospasm. Serious complications requiring immediate attention: (1) Significant hemoptysis (>100 mL or frank bleeding) — biopsy of a vascular lesion; position patient affected side down, call provider, prepare for bronchoscopic hemostasis or IR embolization; (2) Pneumothorax — especially after transbronchial biopsy; (3) Respiratory failure/laryngospasm; (4) Infection (post-BAL). Postprocedure nursing care: (1) Maintain NPO until gag reflex returns (typically 2–4 hours); (2) Assess for respiratory distress; (3) Monitor oxygen saturation; (4) Inspect sputum for bleeding; (5) Assess voice and swallowing before oral intake.

Question 8: A patient with asthma presents with severe dyspnea. On assessment, the nurse notes absent breath sounds bilaterally. What is the interpretation of this finding?

The patient has resolved the bronchospasm and is breathing normally
The patient is in severe bronchospasm ('silent chest') — a medical emergency indicating respiratory failure (Correct answer)
Bilateral absence of breath sounds is normal in asthma exacerbations
The patient is hyperventilating; repositioning will restore breath sounds

Correct answer: The patient is in severe bronchospasm ('silent chest') — a medical emergency indicating respiratory failure

A 'silent chest' in asthma indicates such severe bronchospasm and air trapping that virtually no air movement occurs — this is an ominous, life-threatening sign requiring immediate intervention, possibly intubation.

In asthma exacerbations, progression of severity: mild (expiratory wheeze) → moderate (inspiratory + expiratory wheeze, tachypnea, accessory muscle use) → severe (marked respiratory distress, SpO2 < 90%, PCO2 rising) → respiratory failure ('silent chest'). A 'silent chest' — absent breath sounds on auscultation — occurs because bronchoconstriction is so severe there is almost no air movement. This indicates impending respiratory arrest. Paradoxically, wheezing disappearing in the context of worsening distress is an ominous sign (not improvement). Emergency management: immediate IV/SC epinephrine or magnesium sulfate, heliox, continuous albuterol nebulization, IV corticosteroids, and preparation for emergency intubation or mechanical ventilation. Notify provider and anesthesia immediately.

Question 9: A nurse is preparing to administer the influenza vaccine to a patient. Which patient statement requires clarification?

I have a history of Guillain-Barré syndrome 6 years ago
I am allergic to eggs and have had anaphylaxis after eating eggs (Correct answer)
I received the flu vaccine last year and still got sick
I am 8 months pregnant

Correct answer: I am allergic to eggs and have had anaphylaxis after eating eggs

A history of severe egg allergy with anaphylaxis requires special precautions as influenza vaccines were traditionally egg-based. Guidelines now allow vaccination in controlled settings or recommend egg-free alternatives (recombinant or cell-based vaccines).

Egg allergy and influenza vaccination: Traditional inactivated and live attenuated influenza vaccines are grown in eggs. Current ACIP guidelines: (1) Mild egg allergy (hives only): may receive any influenza vaccine; observe 15 minutes after; (2) Severe egg allergy (anaphylaxis): can receive any influenza vaccine in a healthcare setting prepared to manage anaphylaxis (30-minute observation); egg-free alternatives recommended: recombinant vaccine (Flublok) or cell-culture-based vaccine (Flucelvax) — no egg protein; (3) Guillain-Barré syndrome (GBS): history of GBS within 6 weeks of prior flu vaccine is a precaution but not an absolute contraindication; consult provider; GBS >6 weeks ago: may receive vaccine with informed discussion; (4) Pregnancy: inactivated flu vaccine is recommended at any trimester (live attenuated is contraindicated in pregnancy).

Question 10: A patient is placed on a 60% Venturi mask. The nurse notes the patient is still hypoxic with SpO2 of 85%. What is the appropriate action?

Switch to a non-rebreather mask to deliver higher FiO2 (Correct answer)
Increase the flowmeter setting on the current Venturi mask to deliver higher FiO2
Continue current therapy and recheck in 1 hour
Obtain an ABG and wait for results before changing oxygen delivery

Correct answer: Switch to a non-rebreather mask to deliver higher FiO2

A Venturi mask's maximum FiO2 is approximately 60%. If higher oxygen concentrations are needed, a non-rebreather mask (up to 90–95% FiO2) is the next step in oxygen escalation before considering non-invasive or invasive ventilation.

Oxygen delivery devices and FiO2 (at standard flows): (1) Nasal cannula: 1 L = 24%, 2 L = 28%, up to 6 L = ~44%; (2) Simple face mask: 40–60% at 5–10 L/min; (3) Venturi mask: precise FiO2 of 24%, 28%, 31%, 35%, 40%, 60% (controlled entrainment); (4) Non-rebreather mask (NRB): 60–95% at 10–15 L/min (reservoir bag + one-way valves reduce room air entrainment); (5) High-flow nasal cannula (HFNC): up to 100% FiO2 at 60 L/min; (6) Non-invasive ventilation (CPAP/BiPAP): improves oxygenation through PEEP; (7) Endotracheal intubation: 100% FiO2, complete control. When SpO2 is inadequate at maximum Venturi mask FiO2, escalate to NRB mask. Document changes and reassess response promptly.

Question 11: A nurse is caring for a patient with a chest tube inserted for hemopneumothorax. Which finding requires immediate intervention?

Gentle tidaling in the water seal chamber with respirations
Drainage of 250 mL/hr of bright red blood for 2 consecutive hours (Correct answer)
Small air bubbles in the water seal chamber on coughing only
Drainage output of 50 mL/hr initially decreasing over time

Correct answer: Drainage of 250 mL/hr of bright red blood for 2 consecutive hours

Drainage of >200 mL/hr of bright red blood for 2+ hours from a chest tube indicates ongoing hemorrhage (massive hemothorax) and may require surgical intervention (thoracotomy/video-assisted thoracoscopic surgery).

Chest tube monitoring: (1) Tidaling (water oscillating in water-seal chamber): indicates tube patency and lung not fully re-expanded — normal and expected; (2) Bubbling in water-seal: continuous = air leak (expected initially for pneumothorax, then should stop); (3) Suction chamber: gentle bubbling when suction is applied is normal; (4) Drainage: expected sanguineous/serosanguineous, decreasing over time. Hemorrhage indicators: bright red blood at rate > 200 mL/hr × 2 hours, or total > 1500 mL from initial drainage — indicates massive hemothorax requiring surgical intervention. Nursing actions: maintain drainage system below chest level, never clamp without specific order (tension pneumothorax risk), secure all connections, document drainage hourly, keep an occlusive dressing at insertion site in case of dislodgement.

Question 12: A nurse is providing education to a patient about pursed-lip breathing. Which statement best describes the purpose of this technique?

It increases respiratory rate to enhance oxygen delivery
It maintains positive pressure in the airways during exhalation, preventing alveolar collapse and air trapping (Correct answer)
It is used to prevent infection by filtering bacteria during inhalation
It prevents pneumonia by forcing secretions out of the airways

Correct answer: It maintains positive pressure in the airways during exhalation, preventing alveolar collapse and air trapping

Pursed-lip breathing creates positive pressure during exhalation, keeping small airways open longer and reducing air trapping — beneficial for COPD and emphysema where small airways collapse prematurely during expiration.

Pursed-lip breathing (PLB) technique: (1) Breathe in slowly through the nose for 2 counts; (2) Pucker lips as if to whistle; (3) Breathe out slowly through pursed lips for 4 counts (double the inhalation time). Benefits: (1) Creates positive expiratory pressure (PEP) — keeps airways open during exhalation, preventing premature airway collapse (a major problem in emphysema/COPD where airways lack structural support); (2) Reduces air trapping and hyperinflation; (3) Slows respiratory rate; (4) Decreases the work of breathing; (5) Improves CO2 exhalation; (6) Reduces dyspnea during exercise. COPD: loss of lung elastic recoil causes dynamic airway collapse during exhalation → air trapping → barrel chest. PLB is a key self-management technique for COPD.

Question 13: A patient is diagnosed with acute respiratory distress syndrome (ARDS). Which ventilator strategy is evidence-based for this condition?

High tidal volumes (12–15 mL/kg IBW) to fully expand consolidated lung areas
Lung-protective ventilation: low tidal volumes (6 mL/kg IBW), PEEP, and FiO2 titration to minimize ventilator-induced injury (Correct answer)
High FiO2 at 100% continuously to correct the hypoxemia
Controlled hypoventilation to reduce work of breathing without PEEP

Correct answer: Lung-protective ventilation: low tidal volumes (6 mL/kg IBW), PEEP, and FiO2 titration to minimize ventilator-induced injury

ARDS requires lung-protective ventilation: tidal volumes 6 mL/kg IBW (ARDSNet protocol) to prevent volutrauma/barotrauma, PEEP to recruit alveoli, and FiO2 titrated to SpO2 88–95%.

ARDS (Berlin definition): acute onset, bilateral infiltrates, PaO2/FiO2 <300, not fully explained by cardiac failure or fluid overload. Lung-protective ventilation (ARDSNet protocol): (1) Tidal volume 6 mL/kg ideal body weight (IBW) — small tidal volumes prevent volutrauma (overdistension) and atelectrauma; (2) Plateau pressure ≤30 cmH2O; (3) PEEP (positive end-expiratory pressure): keeps alveoli recruited, prevents de-recruitment at end expiration; titrated per PEEP/FiO2 tables; (4) FiO2 titrated to maintain SpO2 88–95% (higher FiO2 causes oxygen toxicity); (5) Permissive hypercapnia — accept higher CO2 to maintain protective settings; (6) Prone positioning: improves V/Q matching, shown to reduce mortality in severe ARDS. High tidal volumes cause barotrauma and worsen outcomes in ARDS.

Question 14: A nurse is caring for a patient with a tracheostomy. Which action is correct when performing tracheostomy care?

Change the entire tracheostomy tube (inner and outer cannula) daily without a second nurse
Clean the inner cannula with a dedicated brush and solution, replace or re-insert, and change the ties while maintaining tube security (Correct answer)
Use povidone-iodine solution for daily stoma care to prevent infection
Apply a tight occlusive dressing to prevent air leakage around the stoma

Correct answer: Clean the inner cannula with a dedicated brush and solution, replace or re-insert, and change the ties while maintaining tube security

Tracheostomy care involves cleaning or replacing the inner cannula (disposable or reusable), cleaning the stoma with sterile saline, and changing tracheostomy ties/velcro collar while a second nurse maintains tube security.

Tracheostomy care protocol: (1) Gather supplies: sterile tracheostomy care kit, sterile saline, pipe cleaners/brush for reusable inner cannula; (2) Don sterile gloves; (3) Remove inner cannula: for reusable — soak in hydrogen peroxide, clean with small brush, rinse with sterile saline, re-insert; disposable — discard and replace with new; (4) Stoma care: clean with sterile saline-dampened gauze, remove crusts, dry thoroughly; (5) Change tracheostomy ties: CRITICAL — have a second nurse hold the outer cannula to prevent accidental decannulation; do not remove old ties until new ones are secured; ties should allow 1 finger breadth under them; (6) Place sterile tracheostomy dressing (pre-cut gauze) under the plate; (7) Document. Povidone-iodine can impair wound healing and damage skin — sterile saline is preferred.

Question 15: A patient with a history of smoking presents with a chronic productive cough, dyspnea, and barrel chest. Spirometry reveals FEV1/FVC ratio of 0.55 (below the normal 0.70). Which diagnosis does this support?

Restrictive lung disease (pulmonary fibrosis)
Chronic obstructive pulmonary disease (COPD) (Correct answer)
Asthma with reversible obstruction
Pulmonary hypertension

Correct answer: Chronic obstructive pulmonary disease (COPD)

An FEV1/FVC ratio <0.70 post-bronchodilator indicates airflow obstruction (COPD). Combined with smoking history, barrel chest, chronic productive cough, and dyspnea, this is consistent with COPD (emphysema and/or chronic bronchitis).

Pulmonary function testing interpretation: FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity. FEV1/FVC ratio: < 0.70 (or < 70%) = obstructive pattern (COPD, asthma); ≥ 0.70 = normal or restrictive (FVC↓, FEV1 proportionally reduced). COPD severity by FEV1 (% predicted post-bronchodilator): GOLD 1 (mild): ≥80%; GOLD 2 (moderate): 50–79%; GOLD 3 (severe): 30–49%; GOLD 4 (very severe): <30%. Barrel chest results from air trapping (increased RV and TLC). Chronic bronchitis: productive cough ≥3 months/year for ≥2 years. Emphysema: destruction of alveolar walls (enlargement of airspaces). In restrictive disease (fibrosis): FEV1/FVC normal or elevated (both FEV1 and FVC reduced proportionally, FVC affected more). Asthma: FEV1/FVC low but reversible with bronchodilator (≥12% and ≥200 mL improvement).

Question 16: A patient is diagnosed with active tuberculosis (TB). Which precautions should the nurse implement?

Contact precautions with gloves and gown only
Airborne precautions: negative pressure room, N95 respirator, and limiting patient transport (Correct answer)
Droplet precautions with surgical mask for staff
Standard precautions only — TB is not contagious after 24 hours of treatment

Correct answer: Airborne precautions: negative pressure room, N95 respirator, and limiting patient transport

TB is transmitted by airborne droplet nuclei (<5 microns) that remain suspended in air. Airborne precautions require a negative-pressure isolation room and N95 (or higher) respirator for anyone entering the room.

Tuberculosis (Mycobacterium tuberculosis) transmission: airborne — expelled during coughing, sneezing, singing as droplet nuclei (1–5 μm), which remain suspended in air for hours. Airborne precautions requirements: (1) Negative pressure isolation room (air pressure lower than hallway — air flows INTO the room, preventing spread; minimum 12 air changes/hour, exhausted outdoors or HEPA filtered); (2) N95 respirator (or higher — PAPR) for all entering — must be fit-tested; (3) Limit patient transport; when transport necessary, patient wears a surgical mask; (4) Inform receiving departments before transport. Patients remain infectious until: 3 negative AFB smears on consecutive days AND clinical improvement AND <2 weeks of effective therapy. Treatment: RIPE therapy (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) for 6–9 months. Mandatory reporting to public health.

Question 17: A patient is admitted with suspected pulmonary embolism. Which diagnostic test is the gold standard for definitive diagnosis?

D-dimer blood test
CT pulmonary angiography (CTPA) (Correct answer)
Chest X-ray
Ventilation-perfusion (V/Q) scan

Correct answer: CT pulmonary angiography (CTPA)

CT pulmonary angiography (CTPA) is the gold standard for diagnosing PE — it directly visualizes the pulmonary vasculature and identifies filling defects (clots) with high sensitivity (>95%) and specificity.

Pulmonary embolism diagnostic workup: (1) Clinical assessment: Wells criteria for pre-test probability (signs of DVT, alternative diagnosis unlikely, tachycardia, immobilization, prior PE/DVT, hemoptysis, malignancy); (2) D-dimer: high sensitivity, low specificity — useful to RULE OUT PE in low-probability patients (negative D-dimer + low probability = no PE); (3) CTPA: gold standard for diagnosis — IV contrast CT shows filling defects in pulmonary arteries; sensitivity >90%, specificity >95%; contraindicated with contrast allergy or severe renal failure; (4) V/Q scan: alternative when CTPA contraindicated; shows mismatched defects; (5) Pulmonary angiography (conventional): invasive, rarely used since CTPA; (6) Echocardiography: assesses RV strain (in massive PE); (7) Lower extremity ultrasound: if DVT confirmed + high clinical suspicion, may treat without CTPA. Chest X-ray: usually normal or nonspecific in PE.

Question 18: A nurse is caring for a patient with pleural effusion who undergoes thoracentesis. Which complication should the nurse monitor for immediately after the procedure?

Pulmonary hypertension from fluid redistribution
Pneumothorax from inadvertent lung puncture (Correct answer)
Aspiration pneumonia from esophageal injury
Cardiac tamponade from pericardial puncture

Correct answer: Pneumothorax from inadvertent lung puncture

Pneumothorax is the most common serious complication of thoracentesis, caused by inadvertent puncture of the lung with the needle. Post-procedure chest X-ray and monitoring for respiratory distress are essential.

Thoracentesis (pleural fluid aspiration) complications: (1) Pneumothorax (most common serious complication): occurs in 5–20% of procedures; needle puncture of the visceral pleura; monitor for dyspnea, pleuritic chest pain, absent breath sounds; post-procedure CXR at 1 hour (or immediately if symptomatic); (2) Hemothorax: intercostal vessel laceration; (3) Re-expansion pulmonary edema: occurs when large effusion (>1–1.5 L) is removed too rapidly — limit removal to ≤1.5 L per session; symptoms: severe cough, hypoxia, frothy sputum after procedure; (4) Infection/empyema: sterile technique; (5) Vasovagal reaction; (6) Splenic or hepatic laceration (if below 9th rib). Nursing postprocedure care: monitor vitals, SpO2, respiratory status, inspect CXR, assess for subcutaneous emphysema, manage pain.

Question 19: A nurse is teaching a patient about using an incentive spirometer after abdominal surgery. What is the correct technique?

Breathe out forcefully into the device 10 times per hour
Sit upright, exhale completely, seal lips around mouthpiece, inhale slowly and deeply to raise the indicator, hold for 3–5 seconds, perform 10 repetitions hourly (Correct answer)
Lie flat and breathe normally into the device 20 times
Use the device only when experiencing respiratory distress

Correct answer: Sit upright, exhale completely, seal lips around mouthpiece, inhale slowly and deeply to raise the indicator, hold for 3–5 seconds, perform 10 repetitions hourly

Proper incentive spirometry: sit upright (or high Fowler's), exhale fully, place lips around mouthpiece, inhale slowly and deeply to raise the piston/ball, hold 3–5 seconds. Perform 10 times per hour while awake to prevent atelectasis.

Incentive spirometry (IS) purpose: encourages sustained maximal inspiration (SMI), expanding alveoli and preventing atelectasis — especially important after thoracic, abdominal, or cardiac surgery where pain limits deep breathing. Correct technique: (1) Sit upright (or HOB ≥45° minimum); (2) Normal exhalation; (3) Place mouthpiece in mouth, seal lips; (4) Slow, deep inspiration to raise the volume or flow indicator to target level; (5) Hold breath 3–5 seconds (allows alveolar recruitment); (6) Remove mouthpiece, exhale normally; (7) Repeat 10 times every 1–2 hours while awake; (8) Encourage coughing after sessions (mobilizes secretions). Teaching: support incision with pillow during coughing (splinting). Document volumes achieved — improving volume indicates recovery. Contraindication: not a replacement for humidified oxygen or bronchodilators.

Question 20: A patient is receiving BiPAP therapy for acute hypercapnic respiratory failure. Which finding indicates the therapy is effective?

SpO2 decreasing from 86% to 80% after 30 minutes of BiPAP
Respiratory rate decreasing, improved comfort, and ABG showing improved pH and decreased PaCO2 (Correct answer)
Increasing use of accessory muscles and agitation after 1 hour of BiPAP
Developing thick secretions requiring frequent suctioning

Correct answer: Respiratory rate decreasing, improved comfort, and ABG showing improved pH and decreased PaCO2

Effective BiPAP therapy for hypercapnic respiratory failure is demonstrated by decreased respiratory rate, reduced dyspnea, improved comfort, and ABG improvement: pH normalization and PaCO2 reduction.

BiPAP (bilevel positive airway pressure) for hypercapnic respiratory failure (COPD, obesity hypoventilation, neuromuscular disease): delivers inspiratory pressure support (IPAP) to assist breathing + expiratory pressure (EPAP/PEEP) to maintain oxygenation. Indicators of success (should be seen within 1–2 hours): (1) Decreasing respiratory rate (from tachypnea toward normal); (2) Decreasing work of breathing (less accessory muscle use); (3) Improved patient comfort; (4) Improving mental status; (5) ABG improvement: pH normalization (↑ from acidosis), PaCO2 decreasing, PaO2 increasing. Indicators of failure requiring intubation: (1) Worsening ABG despite 1–2 hours of BiPAP; (2) Unable to tolerate mask/interface; (3) Hemodynamic instability; (4) Decreased consciousness; (5) Excessive secretions. BiPAP reduces intubation rates in COPD by ~50%.

NCLEX Medical-Surgical: Respiratory Conditions 1

A patient with COPD is admitted for exacerbation.
Which oxygen delivery goal is most appropriate for this patient?

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