NCLEX-RN cheat sheet · Respiratory

Oxygenation, asthma and COPD

Hypoxia, oxygen devices, suctioning, asthma action plans, COPD oxygen

AI-checkedChecked by AI against current guidelines, with spot-checks by a registered nurse.

Restlessness, not a blue face, is the first sign a client can't get enough oxygen. Asthma comes and goes; COPD only gets worse.

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At a glance

Hypoxia and pulse oximetry

Early: anxiety, restlessness, confusion, a rising heart rate.
Worsening: consciousness falls, breathing speeds up, the saturation drops.
Late: blue around the lips and mouth. Clubbed fingertips mean chronic hypoxia.
High carbon dioxide: fast pulse, flushed skin, headache, confusion.
SpO2 target: usually 95% and above in adults; with COPD and carbon dioxide retention, often 88 to 92%, as prescribed.
False readings: motion, skin pigmentation bias, cold fingers, poor circulation. Warm the hand, or use an ear, forehead or nose probe. Carbon monoxide gives a falsely high reading.

Oxygen in COPD

Aim for the prescribed saturation, usually 88 to 92%.
Titrate the device and flow to that target and the blood gases: no default ceiling.
Why: too much oxygen can depress breathing and raise carbon dioxide further.
Monitor the saturation, breathing rate and alertness closely, and adjust within the target.
Long-term home oxygen needs stable, confirmed severe hypoxemia plus clinical criteria, not a single saturation reading.

Oxygen devices

Device	Flow	Key points
Nasal cannula	Commonly 1 to 6 L/min	Client can eat and talk. Pad the tubing, check nose and ears, never petroleum jelly
Simple mask	A minimum flow, commonly 5 L/min, per the manufacturer	So the client doesn't rebreathe carbon dioxide
Non-rebreather	10 to 15 L/min	High oxygen levels without a breathing tube. Inflate the bag first; it should never deflate completely: if it does, act at once
Venturi mask	Correct adaptor and flow; enough total flow	Often for COPD. Gives the selected oxygen percentage only when set up that way
High-flow cannula	Up to 60 L/min	Heated, humidified oxygen, for critically ill clients
Bag valve mask (adult)	15 L/min	Pulse but inadequate breathing: 1 breath every 6 seconds. Arrest without an advanced airway: 30:2

Follow policy: Each device has its own flow: follow the manufacturer's instructions. Under agency protocol, the nurse can start oxygen without an order, then call the provider or rapid response. Recheck within minutes; escalate if there's no improvement.

Asthma action plan

Zone	What it means	What to do
Green	80% of personal best or more; no symptoms	Keep taking the controllers. If exercise is a trigger, the plan may add quick-relief before exercise
Yellow	50 to 79%, or coughing, wheezing or waking at night	Add the quick-relief inhaler, possibly an oral steroid, and call the provider
Red	Peak flow under 50% of personal best, or very short of breath with quick-relief not helping	Quick-relief and an oral steroid, and call. Still red after 15 minutes, with no provider reached: go to the emergency department
Call 911	Trouble walking or talking, or blue lips or nails	Another quick-relief dose and a 911 call

Peak flow: Peak flow compares how fast air is blown out with the client's personal best. Every client with asthma should have a written action plan.

Asthma drugs

Usually, quick-relief drugs like albuterol treat an attack; controllers prevent attacks.
In some plans, the reliever is an inhaled steroid with formoterol.
Inhaled corticosteroids are the base: take them exactly as prescribed, even when well; rinse and spit after each use to prevent thrush.
A long-acting bronchodilator (LABA) is only used for asthma together with an inhaled steroid.
Montelukast: watch for mood or behavior changes, and report them.
Metered-dose inhaler: shake, breathe out, seal the lips, press while breathing in slowly and deeply; other types differ. Hold about 10 seconds; wait a minute before a second puff.

COPD

Long-term airflow obstruction: progressive and incurable. Smoking is the main cause, and stopping is the most important treatment.
Chronic bronchitis: a productive cough at least 3 months a year, 2 years in a row. Emphysema: trapped air; the lungs overinflate. Most clients have both.
Stable COPD: some clients have compensated respiratory acidosis, but many have a normal carbon dioxide.
Flare-up, often from infection: worse breathlessness and a saturation below baseline; with infection, fever, more cough, thick discolored sputum. Report it promptly.
Teach pursed-lip and belly breathing with a return demonstration. Ipratropium can cause a dry mouth.

Suctioning (adult)

Step	Rule
Pressure	100 to 150 mmHg, never above 150
First	Assess. Oxygenate before nasal and tracheal suctioning
Technique	Insert without suction; suction only while withdrawing and rotating
Each pass	No more than 10 to 15 seconds; 30 to 60 seconds of recovery between
Tracheostomy	Sterile. 100% oxygen for 30 to 60 seconds first; limit it to two passes

Pulmonary hygiene: Incentive spirometer: slow, deep breath in, hold at least 5 seconds; repeat as ordered, commonly 10 times an hour while awake.

Priority and safety calls

★ Restlessness, anxiety or confusion can be early hypoxia: act. Don't wait for cyanosis; it's a late sign.
★ A silent chest in an asthma attack means almost no air is moving: treat it as an emergency.
Heart rate drops during suctioning: stop suctioning and oxygenate the client, then assess again.
Non-rebreather bag collapses completely with each breath: a problem that needs action right away.
Calm, pink client with cold hands and a low finger reading: warm the hand or use an ear probe, then recheck.
Status asthmaticus: oxygen, nebulized bronchodilators and steroids. The steroid route and IV magnesium depend on severity and response.
During any attack: sit the client upright, coach pursed-lip breathing, give the prescribed drugs, and check that they work.
Oxygen makes fires start and spread more easily: no smoking, at least 6 feet from heat and open flame (farther if the supplier or facility says so), no sparks from electric razors or hair dryers.
Oxygen is a medication: don't change it without the provider or respiratory therapist.

How the NCLEX tests it

Restlessness and confusion come early; cyanosis is late.
A simple mask run under its minimum flow (commonly 5 L/min) is a trap.
Suction at 100 to 150 mmHg, only while withdrawing, 15 seconds at most per pass.
Usually quick-relief treats an attack; a slow controller for an attack is a trap.
Yellow zone: 50 to 79% of personal best, or symptoms. Add rescue and call.
A quieter chest read as better is a trap: a silent chest is an emergency.
COPD: oxygen titrated to the prescribed target, usually 88 to 92%. Oxygen above the target is a trap.

Practice it next

This sheet comes from Oxygenation, suctioning and pulmonary hygiene and Asthma and COPD in our NCLEX-RN course. Try free practice questions, or see the lessons it was written from.

Free NCLEX practice questions The NCLEX-RN course

Quick self-quiz

The first sign of hypoxia isn't a blue face; it's ___.
Show answer
restlessness
Keep adult suction pressure between 100 and ___ mmHg.
Show answer
150
A non-rebreather runs at 10 to ___ L/min.
Show answer
15
Carbon monoxide gives a falsely ___ SpO2 reading.
Show answer
high
The yellow zone is 50 to ___ percent of personal best.
Show answer
79
After an inhaled steroid, rinse and ___ to prevent thrush.
Show answer
spit
In COPD, aim for the prescribed saturation, usually 88 to ___ percent.
Show answer
92

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Sources

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