A
A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse prioritize?
A. The client will successfully mobilize pulmonary secretions.
B. The client will maintain an oxygen saturation level of 98%.
C. The client's pulmonary blood pressure will decrease to within reference ranges.
D. The client will resume prediagnosis level of function within 72 hours.
ANS: A
Rationale: Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Pulmonary pressures are not a central focus in the care of the client with bronchiectasis. Rapid resumption of prediagnosis function and oxygen saturation above 98% are unrealistic goals.
An interdisciplinary team is planning the care of a client with bronchiectasis. What aspects of care should the nurse anticipate? Select all that apply.
A. Occupational therapy
B. Antimicrobial therapy
C. Positive pressure isolation
D. Chest physiotherapy
E. Smoking cessation
ANS: B, D, E
Rationale: Chest physiotherapy, antibiotics, and smoking cessation are cornerstones of the care of clients with bronchiectasis. Occupational therapy and isolation are not normally indicated.
A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a correct understanding of this medication?
A. "This drug may make my heart beat slower."
B. "This drug is particularly good at preventing asthma attacks during exercise."
C. "I'll make sure to use this each time I feel an asthma attack coming on."
D. "I understand that this drug is less effective at controlling night-time symptoms."
B
Rationale: LABAs are effective in the prevention of exercise-induced asthma. They are also used with anti-inflammatory medications to control asthma symptoms, particularly those that occur during the night. LABAs are not indicated for immediate relief of symptoms. are not used for management of acute asthma symptoms. Tachycardia, not bradycardia, is a potential adverse effect of this medication.
A nurse is providing health education to the family of a client with bronchiectasis. Which technique should the nurse prioritize teaching the client's family members?
A. The correct technique for chest palpation and auscultation
B. Techniques for assessing the client's fluid balance
C. The technique for providing deep nasotracheal suctioning
D. The correct technique for providing postural drainage
ANS: D
Rationale: A focus of the care of bronchiectasis is helping clients clear pulmonary secretions; consequently, clients and families are taught to perform postural drainage. Chest palpation and auscultation and assessment of fluid balance are not prioritized over postural drainage. Nasotracheal suctioning is not normally necessary.
A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma? Select all that apply.
A. Chest tightness
B. Crackles
C. Bradypnea
D. Wheezing
E. Cough
ANS: A, D, E
Rationale: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.
A nurse is developing a care plan for a client with chronic obstructive pulmonary disease (COPD) admitted to the hospital for the second time this year with pneumonia. Which nursing diagnoses would be appropriate for this client? Select all that apply.
A. Ineffective airway clearance related to inhalation of toxins
B. Activity intolerance related to oxygen supply and demand
C. Impaired gas exchange related to ventilation-perfusion inequality
D. Ineffective health management related to fatigue
E. Deficient knowledge regarding self-care related to preventable complications
ANS: C, E
Rationale: Impaired gas exchange and deficient knowledge are the appropriate diagnoses for this client based on the information provided. Pneumonia is an acute infection of the parenchyma whose pathophysiology typically triggers an inflammatory response in the lung. In a client with COPD who already has chronic inflammation, gas exchange becomes further compromised. Areas of the lung receive either oxygen but no blood flow or blood flow but no oxygen (ventilation/perfusion inequality). Because this was the second admission for the same diagnosis, deficient knowledge of prevention strategies should be included for this client. Although ineffective airway clearance is a possibility, not enough information is provided to conclude that it was a result of toxins such as cigarette smoke. Activity intolerance and health management should be addressed as a risk because pneumonia and COPD impact activity and cause fatigue, but not enough information was provided to make these a problem.
A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching?
A. Increased respiratory secretions
B. Bradycardia
C. Oral candidiasis
D. Decreased level of consciousness
ANS: C
Rationale: Thrush or oral candidiasis is a fungal infection that presents with white lesions on the tongue and/or inner cheeks of the mouth. Clients should rinse their mouth after administration or use a spacer to prevent thrush, a common complication associated with use of inhaled corticosteroids. Increased respiratory secretions normally do not occur, although a cough may develop. Tachycardia, or a fast heart rate, rather than bradycardia, or a slow heart rate, is listed as an adverse effect. A decreased level of consciousness is not associated with this medication because it does not cause sedation nor is it an opiate.
A nurse is explaining to a client with asthma with a new prescription for prednisone what it is used for. What would be the most accurate explanation that the nurse could give?
A. To ensure long-term prevention of asthma exacerbations
B. To cure any systemic infection underlying asthma attacks
C. To prevent recurrent pulmonary infections
D. To gain prompt control of inadequately controlled, persistent asthma
ANS: D
Rationale: Prednisone is used for a short-term (3–10 days) "burst" to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term.
An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients?
A. Encouraging clients to carry a corticosteroid rescue inhaler at all times
B. Educating clients about recognizing and avoiding asthma triggers
C. Teaching clients to utilize alternative therapies in asthma management
D. Ensuring that clients keep their immunizations up to date
ANS: B
Rationale: Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate clients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations.
An asthma educator is teaching a client newly diagnosed with asthma and the family about the use of a peak flow meter. The educator should teach the client that a peak flow meter measures highest airflow during which type of breath?
A. Forced inspiration
B. Forced expiration
C. Normal inspiration
D. Normal expiration
ANS: B
Rationale: Peak flow meters measure the highest airflow during a forced expiration.
A nurse is admitting a new client who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the client achieve the goal of maintaining effective oxygenation?
A. Teach the client strategies for promoting diaphragmatic breathing.
B. Administer supplementary oxygen by simple face mask.
C. Teach the client to perform airway suctioning.
D. Assist the client in developing an appropriate exercise program.
ANS: A
Rationale: The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in clients with COPD. Supplementary oxygen is not normally delivered by simple face mask and exercise may or may not be appropriate.
A client's plan of care specifies postural drainage. Which action should the nurse perform when providing this noninvasive therapy?
A. Administer the treatment with the client in a high Fowler or semi-Fowler position.
B. Perform the procedure immediately following the client's meals.
C. The client is instructed to avoid coughing during the therapy.
D. Assist the client into a position that will allow gravity to move secretions.
ANS: D
Rationale: In postural drainage, the client assumes a position that allows gravity to facilitate the draining of secretions from all areas of the lungs. Postural drainage is usually performed two to four times per day, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Because the client usually sits in an upright position (i.e., high- or semi-Fowler position), secretions are likely to accumulate in the lower parts of the lungs. Several other positions are used in postural drainage so that the force of gravity helps move secretions from the smaller bronchial airways to the main bronchi and trachea. The client is encouraged to cough and remove secretions during postural drainage.
The home care nurse is assessing a client who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the client in the home environment?
A. The client desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min.
B. The client requires a high-flow system for use with a tracheostomy collar.
C. The client desires a portable oxygen delivery system that can deliver 2 L/min.
D. The client's respiratory status requires a system that provides an FiO2 of 65%.
ANS: C
Rationale: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The client desiring a portable oxygen delivery system of 2 L/min will benefit from the use of an oxygen concentrator.
A client with a severe exacerbation of chronic obstructive pulmonary disease requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe?
A. Nonrebreathing mask
B. Tracheostomy collar
C. Venturi mask
D. Face tent
ANS: C
Rationale: The Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means. It is used primarily for clients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The Venturi mask uses the Bernoulli principle of air entrainment (trapping the air like a vacuum), which provides a high airflow with controlled oxygen enrichment. For each liter of oxygen that passes through a jet orifice, a fixed proportion of room air is entrained. Varying the size of the jet orifice and adjusting the flow of oxygen can deliver a precise volume of oxygen. The other methods of oxygen delivery listed, the nonrebreathing mask, tracheostomy collar, and face tent, do not use the Bernoulli principle and thus lack the precision of a Venturi mask.
The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. Which method of oxygen delivery is most appropriate for the client's needs?
A. Nonrebreathing mask
B. Nasal cannula
C. Venturi mask
D. Partial-rebreathing mask
ANS: B
Rationale: A nasal cannula is used when the client requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for clients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The client's respiratory status does not require a partial- or non-rebreathing mask.