NLE Respiratory Nursing — Chronic Obstructive & Restrictive Pulmonary DisordersExam Answer Templates

Marks

1

Topic

Chronic Bronchitis (COPD)

Difficulty

easy

Template Id

T1

Examiner Tip

The time criterion is non-negotiable for full marks — '3 months in 2 consecutive years' is the diagnostic hallmark that differentiates chronic bronchitis from acute bronchitis. Examiners specifically look for this.

Model Answer

Chronic bronchitis is clinically defined as a productive cough lasting for at least 3 months in 2 consecutive years, caused by chronic airway inflammation with mucus-gland hypertrophy and excessive mucus secretion.

Question Type

very_short_answer

Answer Structure

• Line 1: State the clinical definition including the time criterion (3 months in 2 consecutive years) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating 'chronic cough' without specifying it is PRODUCTIVE loses the mark
• Omitting the specific time criterion (3 months / 2 consecutive years) is the most common error
• Writing a vague answer like 'inflammation of the bronchi' without clinical criteria

Key Phrases To Include

• productive cough
• 3 months
• 2 consecutive years
• chronic airway inflammation
• mucus-gland hypertrophy

Marks

2

Topic

COPD Oxygen Therapy

Difficulty

medium

Template Id

T2

Examiner Tip

This is a HIGH-YIELD NLE question. Examiners want both the exact number range AND the physiological mechanism. Writing 'to prevent suppression of the hypoxic drive' specifically earns the second mark. Always mention the Venturi mask as the preferred oxygen delivery device for COPD.

Model Answer

The safe target SpO2 for a COPD patient is 88–92%. This is because chronic CO2 retainers may rely on a hypoxic drive (low PaO2) to stimulate ventilation. Administering high-flow oxygen raises PaO2 excessively, suppressing the hypoxic drive, which can lead to hypoventilation and CO2 narcosis.

Question Type

short_answer

Answer Structure

• Line 1: State the specific SpO2 target range: 88–92% [1 mark]
• Line 2: Explain the rationale — hypoxic drive suppression leading to CO2 narcosis if high-flow oxygen is given [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating the normal SpO2 target of 94–98% instead of 88–92% — this is a critical clinical error
• Stating the target correctly but failing to explain the rationale (hypoxic drive) — scores only 1 of 2
• Saying 'to prevent oxygen toxicity' as the sole reason — this is incomplete and misses the hypoxic drive mechanism

Key Phrases To Include

• SpO2 88–92%
• hypoxic drive
• CO2 retainers
• CO2 narcosis
• hypoventilation
• Venturi mask

Marks

2

Topic

COPD Classification

Difficulty

easy

Template Id

T3

Examiner Tip

Create a two-column comparison in your answer — this visual separation makes it easier for examiners to award marks and shows organized clinical thinking. Always link the mnemonic to the correct underlying disorder.

Model Answer

Blue Bloater (Chronic Bronchitis): The patient appears cyanotic and oedematous due to hypoxaemia and cor pulmonale. There is copious purulent sputum, productive cough, hypercapnia, and right-sided heart failure. Pink Puffer (Emphysema): The patient is thin-appearing with a barrel chest and uses pursed-lip breathing and accessory muscles. There is minimal cough, predominant dyspnoea on exertion, and relatively maintained PaO2 due to increased respiratory effort.

Question Type

short_answer

Answer Structure

• Part 1: Describe Blue Bloater — cyanosis, oedema, productive cough, copious sputum, cor pulmonale (Chronic Bronchitis) [1 mark]
• Part 2: Describe Pink Puffer — barrel chest, pursed-lip breathing, thin/wasted, minimal cough, dyspnoea on exertion (Emphysema) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Mixing up the two presentations (e.g., saying barrel chest is in chronic bronchitis)
• Listing only one feature per type instead of at least two
• Failing to link Blue Bloater to chronic bronchitis and Pink Puffer to emphysema

Key Phrases To Include

• Blue Bloater
• Pink Puffer
• cyanosis
• oedema
• cor pulmonale
• barrel chest
• pursed-lip breathing
• productive cough
• accessory muscles
• dyspnoea on exertion

Marks

2

Topic

COPD Nursing Diagnoses

Difficulty

medium

Template Id

T4

Examiner Tip

Use Maslow's Hierarchy to justify priority — physiological survival needs (gas exchange, airway) always rank above safety, love, or self-esteem needs. Examiners in the NLE reward correct NANDA three-part format and correct prioritization logic.

Model Answer

1. Impaired Gas Exchange related to alveolar destruction and ventilation-perfusion mismatch, as evidenced by PaO2 < 60 mmHg, cyanosis, and altered level of consciousness. 2. Ineffective Airway Clearance related to excessive mucus secretion and ineffective cough, as evidenced by copious purulent sputum, adventitious breath sounds (rhonchi/wheezing), and dyspnoea.

Question Type

short_answer

Answer Structure

• Nursing Diagnosis 1: Impaired Gas Exchange (most priority — Maslow physiological/survival need) with Related Factor and As Evidenced By [1 mark]
• Nursing Diagnosis 2: Ineffective Airway Clearance with Related Factor and As Evidenced By [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing the nursing diagnosis without the 'related to' and 'as evidenced by' components — NANDA format requires all three parts
• Choosing inappropriate priority diagnoses (e.g., Activity Intolerance before Impaired Gas Exchange)
• Using medical diagnoses instead of NANDA-format nursing diagnoses (e.g., writing 'COPD exacerbation' as the diagnosis)

Key Phrases To Include

• Impaired Gas Exchange
• Ineffective Airway Clearance
• related to
• as evidenced by
• ventilation-perfusion mismatch
• alveolar destruction
• excessive mucus secretion
• Maslow

Marks

2

Topic

COPD Nursing Interventions / Patient Teaching

Difficulty

easy

Template Id

T5

Examiner Tip

The physiological reason is what earns the second mark — not just saying 'it helps.' Write the mechanism: back-pressure keeps airways open, preventing collapse, which reduces air trapping. This level of clinical detail distinguishes full-mark answers from partial ones.

Model Answer

Pursed-lip breathing technique: The patient inhales slowly through the nose for 2 counts, then exhales slowly through pursed (puckered) lips — as if blowing out a candle — for twice as long (4 counts), ensuring a controlled, prolonged exhalation. Benefit: This technique creates back-pressure that keeps small airways open longer during exhalation, reducing air trapping and dynamic airway collapse, thereby decreasing the sensation of dyspnoea and improving gas exchange.

Question Type

short_answer

Answer Structure

• Part 1: Describe the correct steps — inhale through nose, exhale slowly through pursed lips (2:4 ratio) [1 mark]
• Part 2: State and explain one benefit — keeps airways open, reduces air trapping, decreases dyspnoea [1 mark]

Scoring Breakdown

Common Mark Deductions

• Reversing the technique — saying exhale through the nose instead of through pursed lips
• Stating the benefit vaguely as 'helps breathing' without explaining the physiological mechanism
• Omitting the instruction about prolonged exhalation (exhale twice as long as inhale)

Key Phrases To Include

• inhale through the nose
• exhale through pursed lips
• prolonged exhalation
• back-pressure
• air trapping
• dynamic airway collapse
• dyspnoea

Marks

3

Topic

Pulmonary Diagnostics — Spirometry

Difficulty

medium

Template Id

T6

Examiner Tip

Draw a simple two-column table in your answer: COPD vs Restrictive with FEV1, FVC, and FEV1/FVC values. This structured comparison earns all three marks efficiently and demonstrates organized clinical reasoning — a habit examiners reward.

Model Answer

In COPD (obstructive pattern): Spirometry shows an FEV1/FVC ratio of less than 70% that is NOT fully reversible after bronchodilator administration. The FVC may be normal or slightly reduced, but the FEV1 is significantly reduced due to airflow obstruction. The chest X-ray corroborates with hyperinflation, flattened diaphragms, and an increased AP diameter. In Restrictive Lung Disease: Spirometry shows a REDUCED FVC (the lungs cannot fully expand), but the FEV1/FVC ratio is NORMAL or INCREASED because airflow itself is not obstructed — the problem is reduced lung volume from stiff or compressed lung tissue (e.g., pulmonary fibrosis, kyphoscoliosis, obesity). Key Differentiator: COPD = reduced FEV1/FVC ratio (airflow obstruction); Restrictive = reduced FVC with preserved or increased FEV1/FVC ratio (volume restriction, not flow obstruction).

Question Type

short_answer

Answer Structure

• Point 1: COPD spirometry — FEV1/FVC < 70%, not reversible, reduced FEV1 [1 mark]
• Point 2: Restrictive disease spirometry — reduced FVC, normal/increased FEV1/FVC ratio, no airflow obstruction [1 mark]
• Point 3: Clear statement of the key differentiator between the two patterns [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing the spirometry patterns — stating restrictive disease has reduced FEV1/FVC is a critical error
• Omitting the word 'reversible' when describing COPD (this differentiates it from asthma)
• Not stating the specific threshold (< 70%) for the FEV1/FVC ratio in COPD

Key Phrases To Include

• FEV1/FVC < 70%
• not fully reversible
• reduced FVC
• normal or increased FEV1/FVC ratio
• airflow obstruction
• volume restriction
• bronchodilator
• hyperinflation

Marks

3

Topic

COPD / Asthma Pharmacology

Difficulty

medium

Template Id

T7

Examiner Tip

The 'rinse mouth after ICS' teaching point appears on the NLE repeatedly. Write it explicitly and boldly — 'rinse mouth with water and gargle after EVERY dose of inhaled corticosteroid.' Examiners specifically look for this. Also link spacer use to improved medication delivery and reduced side effects.

Model Answer

1. Salbutamol (Short-Acting Beta-2 Agonist / SABA — Reliever): Purpose: Provides rapid bronchodilation by relaxing bronchial smooth muscle during acute bronchospasm or dyspnoea. Used as a rescue medication. Teaching: Use only when symptomatic (rescue). Side effects include tachycardia and tremors — reassure patient these are expected but report if severe. Use before exercise to prevent exercise-induced bronchospasm. 2. Fluticasone (Inhaled Corticosteroid / ICS — Controller): Purpose: Reduces chronic airway inflammation, decreasing frequency and severity of exacerbations. Must be used DAILY even when symptom-free. Teaching: CRITICAL — rinse mouth with water and gargle after EVERY use to prevent oral candidiasis (oropharyngeal thrush). Do not skip doses. Report any white patches in the mouth immediately. Nursing Teaching Priority: Demonstrate correct MDI inhaler technique with a spacer device. Never substitute the reliever for the controller or vice versa.

Question Type

short_answer

Answer Structure

• Drug 1 (Salbutamol): Classification (SABA/reliever) + purpose (acute bronchospasm/rescue) + teaching (side effects: tachycardia/tremor) [1 mark]
• Drug 2 (Fluticasone): Classification (ICS/controller) + purpose (daily anti-inflammatory) + teaching (MUST rinse mouth after use to prevent oral candidiasis) [1 mark]
• Additional teaching: correct inhaler technique, spacer use, never substitute one for the other [1 mark]

Scoring Breakdown

Common Mark Deductions

• Failing to mention 'rinse mouth after ICS use' — this is the most commonly tested ICS teaching point
• Not distinguishing reliever (as needed/rescue) from controller (daily/preventive)
• Listing side effects of salbutamol without mentioning the most common ones: tachycardia and tremor

Key Phrases To Include

• SABA
• reliever
• rescue medication
• tachycardia
• tremor
• ICS
• controller
• rinse mouth
• oral candidiasis
• spacer
• daily
• inhaler technique

Marks

3

Topic

Pneumothorax — Emergency Management

Difficulty

hard

Template Id

T8

Examiner Tip

Tracheal deviation to the UNAFFECTED (opposite) side is the most specific and tested NLE finding for tension pneumothorax — never mix this up. The sequence is critical: needle decompression FIRST, then chest tube. Stating this correct sequence alone may differentiate a passing from a failing answer.

Model Answer

Priority Assessment Findings (Classic Triad + Additional Signs): A tension pneumothorax is a life-threatening emergency. The hallmark priority assessment findings include: • Tracheal deviation toward the UNAFFECTED side (due to mediastinal shift) • Absent or markedly decreased breath sounds on the AFFECTED side • Severe hypotension and tachycardia (compression of heart and great vessels reduces cardiac output) • Distended neck veins (from elevated intrathoracic pressure obstructing venous return) • Severe respiratory distress, cyanosis, and increasing agitation FIRST Nursing Action: Immediately notify the physician and prepare for and assist with EMERGENCY NEEDLE DECOMPRESSION — insertion of a large-bore needle (14–16 gauge) into the 2nd intercostal space at the midclavicular line on the AFFECTED side to rapidly release trapped air and relieve pressure. This is followed by chest tube insertion (thoracostomy). Simultaneously administer high-flow oxygen and continuously monitor vital signs and SpO2.

Question Type

short_answer

Answer Structure

• Part 1: State the priority assessment findings — tracheal deviation to UNAFFECTED side (most specific finding) + absent breath sounds on affected side + hypotension + distended neck veins [1 mark]
• Part 2: Identify the emergency and state FIRST action — notify physician, prepare for needle decompression at 2nd ICS midclavicular line [1 mark]
• Part 3: Complete the sequence — chest tube insertion follows, administer high-flow oxygen, continuous monitoring [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating tracheal deviation is toward the AFFECTED side — this is a critical factual error (it deviates AWAY from the affected side, toward the unaffected side)
• Not specifying the exact site for needle decompression (2nd ICS, midclavicular line)
• Saying 'chest tube' is the FIRST action — needle decompression comes FIRST in tension pneumothorax before chest tube insertion

Key Phrases To Include

• tracheal deviation
• unaffected side
• absent breath sounds
• hypotension
• distended neck veins
• needle decompression
• 2nd intercostal space
• midclavicular line
• chest tube
• life-threatening emergency
• mediastinal shift

Marks

2

Topic

Pneumothorax — Open Chest Wound Management

Difficulty

medium

Template Id

T9

Examiner Tip

The number 'THREE sides' is the testable fact — say it explicitly. Then add the word 'flutter valve' to name the mechanism. These two elements together — 3 sides + flutter valve — are what examiners reward. Always include the contraindication (4-sided taping = tension pneumothorax) to demonstrate complete understanding.

Model Answer

Management: Apply an OCCLUSIVE DRESSING (e.g., petroleum gauze or clean plastic wrap) taped securely on THREE SIDES ONLY — leaving one side open as a flutter valve. Rationale: The three-sided dressing acts as a one-way flutter valve. On exhalation, the open edge lifts, allowing trapped air to escape from the pleural space. On inhalation, the dressing seals the wound, preventing atmospheric air from entering the pleural space through the chest wall. This prevents progression to a tension pneumothorax. IMPORTANT: Taping all FOUR sides is CONTRAINDICATED because it converts the open pneumothorax into a tension pneumothorax by trapping air with no escape route.

Question Type

short_answer

Answer Structure

• Part 1: State the correct action — occlusive dressing taped on 3 sides only (flutter valve) [1 mark]
• Part 2: Explain the rationale — prevents air entry on inhalation, allows air escape on exhalation; warns that 4-sided taping causes tension pneumothorax [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying 'tape on all four sides' — this is clinically dangerous and incorrect
• Applying any dressing without explaining the flutter valve mechanism
• Not mentioning the danger of converting to a tension pneumothorax if all four sides are taped

Key Phrases To Include

• occlusive dressing
• three sides
• flutter valve
• prevents air entry
• allows air escape
• tension pneumothorax
• contraindicated
• petroleum gauze

Marks

3

Topic

Bronchiectasis

Difficulty

medium

Template Id

T10

Examiner Tip

Bronchiectasis questions almost always focus on the sputum and airway clearance. Use the phrase 'copious purulent foul-smelling sputum' and 'three-layer sputum' — these specific descriptors signal comprehensive knowledge. For the Philippine NLE, always acknowledge the post-TB aetiology as this is highly prevalent in the local context.

Model Answer

Hallmark Clinical Manifestations of Bronchiectasis: Bronchiectasis is defined as permanent, abnormal dilation of the bronchi caused by chronic infection/inflammation (often post-TB in the Philippine setting). Its hallmark features include: 1. Chronic cough producing large volumes of thick, purulent, foul-smelling sputum — classically described as 'three-layer sputum' (frothy top, mucoid middle, purulent sediment at the bottom) 2. Recurrent lower respiratory tract infections 3. Haemoptysis (blood-streaked to frank blood in sputum) 4. Persistent crackles (coarse) on auscultation 5. Digital clubbing (chronic hypoxaemia) PRIORITY Nursing Intervention — Airway Clearance: The PRIORITY intervention is POSTURAL DRAINAGE combined with CHEST PHYSIOTHERAPY (percussion and vibration). The patient is positioned so that the affected lobe is uppermost, using gravity to drain secretions toward larger airways for expectoration. This is performed 2–4 times daily, ideally before meals to prevent nausea and aspiration. Adequate hydration and mucolytic nebulisation are essential adjuncts to thin secretions and facilitate drainage.

Question Type

short_answer

Answer Structure

• Part 1: Describe hallmark manifestations — copious purulent foul-smelling sputum (three-layer), haemoptysis, crackles, clubbing, recurrent infections [1 mark]
• Part 2: Identify priority intervention — postural drainage with chest physiotherapy (percussion/vibration) positioned by gravity [1 mark]
• Part 3: Include clinical details — timing (before meals), adjuncts (hydration, mucolytics), frequency [1 mark]

Scoring Breakdown

Common Mark Deductions

• Failing to describe the classic sputum characteristic (large volumes, foul-smelling, purulent) — this is the defining feature
• Stating 'oxygen therapy' or 'antibiotics' as the priority intervention instead of airway clearance
• Omitting the positioning instruction — saying 'postural drainage' without specifying how the patient is positioned

Key Phrases To Include

• copious purulent sputum
• foul-smelling
• three-layer sputum
• haemoptysis
• clubbing
• postural drainage
• chest physiotherapy
• gravity
• affected lobe uppermost
• before meals
• recurrent infections
• TB

Marks

3

Topic

Asthma — Status Asthmaticus

Difficulty

hard

Template Id

T11

Examiner Tip

The phrase 'silent chest is an OMINOUS sign, NOT an improvement' is exactly what examiners want to read. Write it boldly and early in your answer. Then contrast oxygen management: asthma = high-flow O2 (SpO2 > 92%); COPD = titrated O2 (SpO2 88–92%). This contrast demonstrates high-level clinical differentiation.

Model Answer

Clinical Interpretation — 'Silent Chest': The ABSENCE of wheezing in a severely distressed asthma patient is called a 'SILENT CHEST' and is an OMINOUS, life-threatening sign — NOT a sign of improvement. A silent chest indicates that airflow is so severely reduced (near-complete bronchospasm and mucus plugging) that there is insufficient air movement to generate a wheeze. This signals impending respiratory failure and MUST be treated as a medical emergency. Nursing Diagnoses (Priority): 1. Impaired Gas Exchange (highest priority — life-threatening) 2. Ineffective Breathing Pattern Priority Nursing Actions (in sequence): 1. IMMEDIATELY call the physician and activate the emergency response — this is status asthmaticus 2. Administer HIGH-FLOW OXYGEN to maintain SpO2 > 92% (note: unlike COPD, asthma patients do NOT have hypoxic drive concerns) 3. Administer nebulised salbutamol (SABA) + ipratropium (antimuscarinic) bronchodilators as ordered 4. Administer systemic corticosteroids (IV methylprednisolone or oral prednisone) as ordered to reduce inflammation 5. Prepare IV magnesium sulfate for severe, refractory cases 6. Prepare for possible endotracheal intubation and mechanical ventilation 7. Continuously monitor SpO2, respiratory rate, ABGs, and level of consciousness

Question Type

case_study

Answer Structure

• Part 1: Correctly interpret 'silent chest' — ominous sign, NOT improvement; indicates severe obstruction with near-zero airflow, impending respiratory failure [1 mark]
• Part 2: Priority nursing action — call physician/emergency, administer high-flow oxygen, nebulised SABA + ipratropium [1 mark]
• Part 3: Complete management sequence — systemic steroids, magnesium sulfate, prepare for intubation, continuous monitoring [1 mark]

Scoring Breakdown

Common Mark Deductions

• Interpreting the absence of wheeze as 'improving' — this is a critical clinical error that indicates misunderstanding of the concept
• Not identifying this as a medical emergency (status asthmaticus)
• Failing to state the correct oxygen strategy — unlike COPD, asthma patients receive high-flow oxygen, not restricted O2

Key Phrases To Include

• silent chest
• ominous sign
• impending respiratory failure
• NOT a sign of improvement
• status asthmaticus
• high-flow oxygen
• nebulised salbutamol
• ipratropium
• systemic corticosteroids
• magnesium sulfate
• endotracheal intubation

Marks

3

Topic

COPD — ABG Interpretation

Difficulty

hard

Template Id

T12

Examiner Tip

Always follow the 4-step ABG interpretation: pH → PaCO2 → HCO3 → PaO2. This structured approach earns marks at each step. For COPD ABG questions, the answer almost always ends with 'chronic respiratory acidosis with metabolic compensation' and 'titrate O2 to SpO2 88–92%.' Memorize this pattern cold.

Model Answer

Step 1 — Assess pH: 7.35 → LOW NORMAL (borderline — at the lower limit of normal range 7.35–7.45). Trend indicates acidotic tendency. Step 2 — Assess PaCO2: 58 mmHg → ELEVATED (normal: 35–45 mmHg) → Respiratory ACIDOSIS is the PRIMARY disturbance (CO2 retention = carbonic acid increase). Step 3 — Assess HCO3: 34 mEq/L → ELEVATED (normal: 22–26 mEq/L) → Metabolic COMPENSATION is present (kidneys have retained HCO3 to buffer the chronic CO2 elevation). Step 4 — Assess PaO2: 54 mmHg → CRITICALLY LOW (normal: 80–100 mmHg) → Significant HYPOXAEMIA. Interpretation: CHRONIC Respiratory Acidosis WITH FULL Metabolic Compensation (pH near-normal due to renal HCO3 retention). This is the classic ABG pattern for chronic, stable COPD with CO2 retention. Nursing Priority: 1. Administer controlled low-flow oxygen — target SpO2 88–92% (do NOT give high-flow; risk of suppressing hypoxic drive → CO2 narcosis) 2. Preferred device: Venturi mask for precise FiO2 delivery 3. Monitor level of consciousness, respiratory rate, and SpO2 continuously 4. Position in high-Fowler's or tripod position 5. Prepare for ABG repeat after oxygen titration to monitor response

Question Type

short_answer

Answer Structure

• Part 1: Correctly assess each ABG component systematically — pH borderline, PaCO2 elevated (respiratory acidosis), HCO3 elevated (metabolic compensation), PaO2 low (hypoxaemia) [1 mark]
• Part 2: State the correct interpretation — chronic respiratory acidosis with full metabolic compensation, classic COPD pattern [1 mark]
• Part 3: State the nursing priority — controlled low-flow O2 with SpO2 target 88–92%, Venturi mask, monitoring [1 mark]

Scoring Breakdown

Common Mark Deductions

• Not following a systematic approach — jumping to a conclusion without assessing each component
• Misidentifying the compensation type — saying 'respiratory compensation' instead of 'metabolic (renal) compensation'
• Recommending high-flow oxygen for this patient — the elevated PaCO2 and clinical context require controlled, titrated oxygen

Key Phrases To Include

• respiratory acidosis
• elevated PaCO2
• metabolic compensation
• elevated HCO3
• hypoxaemia
• PaO2 54 mmHg
• chronic
• SpO2 88–92%
• Venturi mask
• hypoxic drive
• CO2 narcosis
• controlled oxygen

Marks

5

Topic

COPD — Comprehensive Nursing Care Plan

Difficulty

hard

Template Id

T13

Examiner Tip

A 5-mark care plan question requires organized structure, correct NANDA format, Maslow-based prioritization, and rationale for EVERY intervention. Use clear headings and bullet points. Examiners award marks section by section — even if one section is weak, a strong other section still earns those marks. Always end with measurable evaluation criteria. Mentioning the Philippine context (biomass smoke, post-TB bronchiectasis) shows local clinical awareness.

Model Answer

NURSING CARE PLAN — COPD PATIENT I. ASSESSMENT DATA (Subjective & Objective) Subjective: 'Nahihirapan akong huminga kahit umuupo na lang' (difficulty breathing even at rest); chronic productive cough; uses 3 pillows at night; history of smoking 20 pack-years; occasional haemoptysis. Objective: SpO2 87% on room air; RR 28 bpm; BP 140/90 mmHg; HR 102 bpm; barrel-shaped chest; use of accessory muscles (sternocleidomastoid, scalene); hyperresonance on percussion; decreased breath sounds bilaterally; coarse crackles and expiratory wheezing; ABG: pH 7.35, PaCO2 60 mmHg, HCO3 36 mEq/L, PaO2 52 mmHg; CXR: flattened diaphragms, hyperinflation. II. NURSING DIAGNOSES (NANDA, Maslow-Prioritized) #1 — HIGHEST PRIORITY (Physiological — Survival) Impaired Gas Exchange related to ventilation-perfusion mismatch and alveolar destruction, as evidenced by PaO2 52 mmHg, SpO2 87%, PaCO2 60 mmHg, and cyanosis. Nursing Interventions: • Administer controlled low-flow O2 via Venturi mask, titrate to target SpO2 88–92% — rationale: prevents CO2 narcosis from suppression of hypoxic drive in chronic CO2 retainers • Position in high-Fowler's or tripod (lean forward on overbed table) — rationale: reduces pressure on the diaphragm, maximises thoracic expansion • Monitor ABGs, SpO2, RR, and LOC every 1–2 hours — rationale: early detection of deterioration or CO2 narcosis • Teach pursed-lip and diaphragmatic breathing — rationale: maintains positive airway pressure, reduces air trapping, improves expiratory flow #2 — HIGH PRIORITY (Physiological — Safety) Ineffective Airway Clearance related to excessive mucus secretion and ineffective cough, as evidenced by coarse crackles, expiratory wheezing, copious sputum, and SpO2 87%. Nursing Interventions: • Encourage oral fluid intake (2–3 L/day unless contraindicated) — rationale: adequate hydration thins bronchial secretions for easier expectoration • Teach controlled cough technique (inhale deeply, hold 2 seconds, cough 2–3 times) — rationale: maximises air behind secretions to expel them effectively • Perform chest physiotherapy and postural drainage — rationale: gravity-assisted drainage mobilises secretions from peripheral to central airways • Administer nebulised bronchodilators (salbutamol, ipratropium) as ordered — rationale: reduces bronchospasm, widening airways for improved airflow and secretion clearance #3 — MODERATE PRIORITY (Physiological — Activity/Nutrition) Activity Intolerance related to imbalance between oxygen supply and demand, as evidenced by dyspnoea on minimal exertion, RR 28 bpm, and HR 102 bpm with activity. Nursing Interventions: • Plan activities during periods of least dyspnoea; incorporate rest periods between activities — rationale: energy conservation reduces oxygen demand • Provide small, frequent, high-calorie, high-protein meals — rationale: large meals elevate the diaphragm, worsening dyspnoea; high-calorie intake compensates for increased metabolic work of breathing • Refer to pulmonary rehabilitation program — rationale: graded exercise training improves functional capacity and quality of life • Counsel on smoking cessation — rationale: the single most effective intervention to slow COPD progression; address biomass cooking smoke exposure in the Philippine home setting III. EVALUATION Patient achieves SpO2 88–92% on controlled O2; demonstrates correct pursed-lip breathing technique; expectorates secretions effectively; tolerates activities of daily living with minimal dyspnoea within 48 hours.

Question Type

long_answer

Answer Structure

• Section I: Assessment data — subjective (dyspnoea, cough) and objective (SpO2, ABG, barrel chest, breath sounds, RR) [1 mark]
• Section II ND #1: Impaired Gas Exchange (NANDA format) + 3–4 interventions with rationale focused on O2 therapy (88–92%), positioning, breathing exercises [1 mark]
• Section II ND #2: Ineffective Airway Clearance (NANDA format) + 3–4 interventions with rationale — hydration, controlled cough, chest physiotherapy, bronchodilators [1 mark]
• Section II ND #3: Activity Intolerance (NANDA format) + interventions — energy conservation, small frequent meals, smoking cessation, pulmonary rehab [1 mark]
• Section III: Evaluation criteria stated as measurable, observable patient outcomes [1 mark]

Scoring Breakdown

Common Mark Deductions

• Using medical diagnoses instead of NANDA nursing diagnoses
• Writing nursing interventions without rationale — rationale is mandatory in a care plan
• Incorrect prioritization — placing Activity Intolerance above Impaired Gas Exchange
• Missing the NANDA three-part format (problem + related factor + as evidenced by) for any diagnosis
• Writing vague evaluation criteria like 'patient will improve' instead of measurable outcomes

Key Phrases To Include

• Impaired Gas Exchange
• Ineffective Airway Clearance
• Activity Intolerance
• related to
• as evidenced by
• SpO2 88–92%
• Venturi mask
• pursed-lip breathing
• controlled cough
• chest physiotherapy
• small frequent meals
• smoking cessation
• rationale
• biomass smoke
• pulmonary rehabilitation

Marks

2

Topic

COPD Pharmacology — Theophylline

Difficulty

medium

Template Id

T14

Examiner Tip

For any narrow-therapeutic-index drug question, always include: the exact range, monitoring requirement, and toxicity signs. For theophylline specifically: 10–20 mcg/mL, tachycardia + seizures = classic toxicity triad with nausea. Caffeine interaction is the most clinically relevant interaction for Filipino patients.

Model Answer

1. Narrow Therapeutic Range — Blood Level Monitoring: Theophylline has a NARROW therapeutic blood level range of 10–20 mcg/mL. The patient must have regular blood level monitoring. Levels below 10 mcg/mL are subtherapeutic (ineffective); levels above 20 mcg/mL cause TOXICITY. Signs of theophylline toxicity include tachycardia, nausea, vomiting, headache, and in severe cases, SEIZURES — report these symptoms IMMEDIATELY. 2. Drug and Food Interactions: Caffeine (coffee, tea, cola drinks, energy drinks) increases theophylline blood levels and worsens side effects — limit or avoid caffeine intake. Smoking reduces theophylline blood levels (enzyme induction), so if the patient starts or stops smoking, the dose may need adjustment. Report all new medications to the physician as many drugs affect theophylline metabolism.

Question Type

short_answer

Answer Structure

• Teaching Point 1: Narrow therapeutic range (10–20 mcg/mL), need for blood level monitoring, signs of toxicity (tachycardia, seizures, nausea) [1 mark]
• Teaching Point 2: Caffeine interaction increases levels; smoking decreases levels; importance of reporting drug interactions [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating the wrong therapeutic range (e.g., '5–15 mcg/mL' or '15–30 mcg/mL')
• Listing only one toxicity sign without the critical seizure warning
• Failing to mention any specific drug or food interaction

Key Phrases To Include

• narrow therapeutic range
• 10–20 mcg/mL
• blood level monitoring
• toxicity
• tachycardia
• seizures
• nausea
• caffeine interaction
• smoking

Marks

3

Topic

Pneumothorax — Assessment

Difficulty

medium

Template Id

T15

Examiner Tip

Classic NLE case study: young + tall + thin + sudden pleuritic pain = spontaneous pneumothorax from ruptured bleb. Memorize the four assessment quadruple: (1) Auscultation, (2) Percussion, (3) Vital signs/SpO2, (4) Tracheal position. Always state the expected FINDINGS alongside the assessment — not just 'auscultate' but 'auscultate — expect absent breath sounds on the affected side.'

Model Answer

Likely Type: PRIMARY SPONTANEOUS PNEUMOTHORAX — This is the classic presentation: a sudden onset of sharp, pleuritic chest pain (worsens with breathing) and dyspnoea in a YOUNG, TALL, THIN MALE at rest, with no preceding lung disease. It is caused by spontaneous rupture of a subpleural bleb (small air-filled sac on the lung surface), allowing air to enter the pleural space and disrupt the negative intrapleural pressure. Four Priority Nursing Assessments: 1. RESPIRATORY ASSESSMENT: Auscultate breath sounds bilaterally — expect DECREASED or ABSENT breath sounds on the LEFT (affected) side due to lung collapse; assess respiratory rate, depth, and work of breathing (accessory muscle use, nasal flaring). 2. PERCUSSION: Percuss the chest bilaterally — expect HYPERRESONANCE on the left (affected) side because air in the pleural space produces a drum-like hollow sound instead of the normal dullness. 3. VITAL SIGNS & SpO2 MONITORING: Obtain baseline SpO2, RR, HR, and BP. Tachycardia and dropping SpO2 signal worsening hypoxaemia. Hypotension suggests progression toward tension physiology. 4. TRACHEAL POSITION ASSESSMENT: Inspect and palpate the trachea for DEVIATION. In a simple pneumothorax, the trachea remains midline. A SHIFT of the trachea toward the UNAFFECTED (right) side indicates progression to TENSION PNEUMOTHORAX — a medical emergency requiring immediate intervention.

Question Type

case_study

Answer Structure

• Part 1: Identify the type — primary spontaneous pneumothorax; explain the classic risk profile (young, tall, thin male, ruptured bleb) [1 mark]
• Part 2: Two nursing assessments — auscultation (absent breath sounds affected side) + percussion (hyperresonance) [1 mark]
• Part 3: Two more assessments — vital signs/SpO2 monitoring + tracheal position assessment (deviation = tension emergency) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Identifying the wrong type of pneumothorax (e.g., tension pneumothorax for the initial presentation)
• Performing assessment on the wrong side — absent breath sounds and hyperresonance are on the AFFECTED (left) side
• Stating tracheal deviation without linking it to the clinical emergency (tension pneumothorax)

Key Phrases To Include

• primary spontaneous pneumothorax
• young tall thin male
• ruptured bleb
• absent breath sounds
• affected side
• hyperresonance
• tracheal deviation
• tension pneumothorax
• SpO2
• pleuritic chest pain