Week 3 Asthma & COPD

Assessment

100

A client with COPD is admitted to an acute care facility because of an acute respiratory infection. When assessing the client’s respiratory status, which finding should the nurse anticipate? 1. An inspiratory- expiratory (I:E) ratio of 2:1 2. A transverse chest diameter twice that of the anterior posterior diameter. 3. An oxygen saturation of 99% 4. A respiratory rate of 12 breaths/min

1. An inspiratory- expiratory (I:E) ratio of 2:1 Rationale: The normal I:E ratio is 1:2, meaning that the expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration.

200

What is an indication of marked bronchoconstriction with air trapping and hyperinflation of the lungs in a patient with asthma? 1. SaO2 of 85% 2. PEF rate of <150 L/min 3. FEV1 of 85% of predicted 4. Chest X-ray showing a flattened diagram

2. PEF rate of <150 L/min Rationale: Peak expiratory rates (PEFR) are normally up to 600 L/min and in status asthmaticus may be as low as 100-150 L/min. An Sa02 of 85% and a FEV1 of 85% of predicted are typical of mild to moderate asthma. A flattened diaphragm may be present in the patient with long-standing asthma but does no reflect current bronchoconstriction.

300

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? 1. An 84 year-old client with heart failure who’s on telemetry and 2L/ minute of oxygen. 2. A 42 year-old client who has left lower lobe pneumonia and an I.V. line. 3. A 48 year-old client with COPD with occasional atrial fibrillation. 4. A 73 year-old client who has pneumonia with coarse crackles, is receiving 2L/min of oxygen, and has an I.V. line.

4. A 73 year-old client who has pneumonia with coarse crackles, is receiving 2L/min of oxygen, and has an I.V. line. Rationale: The 73 year-old client with pneumonia should be the nurse’s priority because elf the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line.

400

The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amount of thick white sputum. 2. Oxygen flowmeter set on eight liters. 3. Use of accessory muscles during inspirations. 4. Presence of a barrel chest and dyspnea.

2. Oxygen flowmeter set on eight liters. Rationale: The nurse should decrease the oxygen rate to two to three liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves the oxygen level increases, the drive to breathe may be eliminated.

500

The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which finding would the nurse expect to note on assessment of this client? Select all that apply. 1. Hypocapnia 2. A hyperinflated chest noted on the chest X-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diagram noted on the chest X-ray 5. Pulmonary function tests that demonstrate increased vital capacity

2. A hyperinflated chest noted on the chest X-ray 3. Decreased oxygen saturation with mild exercise Rationale: clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest X-ray reveals a hyper inflated chest and a flattened diagram if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

Teaching

100

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diagram 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Promote carbon dioxide elimination Rationale: pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation.

200

he nurse is caring for the client diagnosed with COPD. Which outcome requires revision in the plan of care? 1. the client has no signs of respiratory distress. 2. The clients shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

3. The client demonstrates intolerance to activity. Rationale: The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected outcome, the plank of care needs revision.

300

The nurse recognizes that additional teaching is needed when the patient with asthma says: 1. "I should exercise every day if my symptoms are controlled" 2. "I may use OTC bronchodilator drugs occasionally if I develop chest tightness" 3. "I should inform my spouse about my medication and how to get help if I have a severe asthma attack" 4. "A diary to record my medication use, symptoms, peak expiratory flow rates, and activity levels will help me in adjusting my therapy"

2. "I may use OTC bronchodilator drugs occasionally if I develop chest tightness" Rationale: Nonprescription drugs should not be used by patient with asthma because of dangers associated with rebound bronchospasm, interactions with prescribed drugs, and undesirable side effects.

400

Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? 1. Incorporate physical exercise as tolerated into the treatment plan. 2. Monitor peak flow numbers after meals and at bedtime. 3. Eliminate stressors int eh work and home environment. 4. Use sedatives to ensure uninterrupted sleep at night.

1. Incorporate physical exercise as tolerated into the treatment plan. Rationale: Physical exercise is beneficial and should be incorporated as tolerated into the client’s schedule to build tolerance.

500

The client with asthma should be taught that which of the following is one of the most common precipitating factors of an acute asthma attack. 1. Occupational exposure to toxins. 2. Viral respiratory infections. 3. Exposure to cigarette smoke. 4. Exercising in cold temperature.

2. Viral respiratory infections. Rationale: Clients who have asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations.

Intervention

100

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client have expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyperoxygenation and suctioning 4. Administer bronchodilator and monitor peak flow

2. Percussion and vibration Rationale: Chest physiotherapy of percussion and vibration helps loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus.

200

An oxygen delivery system is prescribed for a client with COPD to deliver a precise oxygen saturation. Which oxygen delivery system would the nurse anticipate to be prescribed? 1. Face tent 2. Venturi mask 3. Aersosol mask 4. Tracheostomy collar

2. Venturi mask Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitations because it delivers a precise oxygen concentration.

300

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed and leaning on an overbed table

4. Sitting on the side of the bed and leaning on an overbed table Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaving on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

400

A client with COPD is recovering from an myocardial infarction. Because the client is extremely weak and can’t produce an effective cough, the nurse should monitor closely for: 1. pleural effusion 2. Pulmonary Edema 3. Atelectasis 4. Oxygen Toxicity

3. Atelectasis Rationale: In a client with COPD, an ineffective cough impedes secretion removal. This, in turn causes mucus plugging, which leads to localized airway obstruction = atelectasis.

500

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at 6 LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health care provider about the client’s status.

1. Assist the client into a sitting position at 90 degrees. Rationale: The client should be assisted into a sitting position either on the side of the bed or in the bed. TH exposition decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain client’ s safety.

Pharmacology

100

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer? 1. An inhaled beta-2 adrenergic agonist. 2. An inhaled corticosteroid. 3. An I.V. beta-2 adrenergic agonist. 4. An oral corticosteroid. Rationale: Answer 1. An inhaled beta 2 adrenergic agonist helps promote bronchodilation, which improves oxygenation. I.V. beta 2 agonist is used if the inhaled doesn’t work.

1. An inhaled beta-2 adrenergic agonist. Rationale: An inhaled beta 2 adrenergic agonist helps promote bronchodilation, which improves oxygenation. I.V. beta 2 agonist is used if the inhaled doesn’t work.

200

When teaching the patient about going from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI), which statement by the patient shows the nurse that the patient needs more teaching? 1. "I do not need to use the spacer like I used to" 2. "I will hold my breath for 10seconds or longer if I can" 3. "I will not shake this inhaler like I did with my old inhaler" 4. "I will store it in the bathroom so I will be able to clean it when I need to"

4. "I will store it in the bathroom so I will be able to clean it when I need to" Rationale: Storing the DPI in the bathroom will expose it to moisture, which could cause clumping of the medication and an altered dose.

300

The nurse teaches a client about the effects of diphenhydramine (Benadryl), which has been prescribed as a cough suppressant. The nurse determines that the client needs further teaching instruction if the client makes which statement? 1. "I will take the medication on an empty stomach" 2. "I won't drink alcohol while taking this medication" 3. I will use sugarless gum, candy, or oral rinses to decrease dryness in my mouth" 4. "I won't do activities that require mental alertness while taking this medication"

1. "I will take the medication on an empty stomach" Rationale: diphenhydramine (Benadryl) has several uses including as an antihistamine, antitussive, antidyskinetic, and sedative-hypnotic. Instructions for use include taking with food or milk to decrease GI upset and using oral rinses or sugarless gum or hard candy to minimize dry mouth. Because the medication causes drowsiness, the client should avoid use of alcohol or CNS depressants, operating a car, or engaging in other activities requiring mental awareness during use.

400

Zafirlukast(Accolate) is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? 1. Platelet count 2. Neutrophil count 3. Liver function tests 4. Complete blood count

3. Liver function tests Rationale: Zafirlukast(Accolate) is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. It is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication.

500

A client has been taking flunisolide (Aerobid), two inhalations a day, for treatment of asthma. He tells the nurse that he has painful, white patches in his mouth. Which response by the nurse would be the most appropriate? 1. “This is an anticipated side-effect of your medications. IT should go away in a couple of weeks.” 2. “You are using your inhaler too much and it has irrupted your mouth. “ 3. “You have developed a fungal infection from your medication. It will need to be treated with an antibiotic.” 4. “Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem.”

3. “You have developed a fungal infection from your medication. It will need to be treated with an antibiotic.” Rationale: Use of oral inhalant corticosteroids, such as flunisolide, can lead to the development of oral thrush a fungal infection; it will not resolve on its own.

Priority

100

A client is admitted to a health care facility for treatment of COPD. Which nursing diagnosis is most important for this client? 1. Activity intolerance related to fatigue. 2. Anxiety related to actual threat to health status. 3. Risk for infection related to retained secretions. 4. Impaired gas exchange related to airflow obstruction.

4. Impaired gas exchange related to airflow obstruction. Rationale: A patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis.

200

Question 4: A client with COPD tells a nurse he feels short of breath. The client’s respiratory rest is 36 breaths/min and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer an ordered nebulizer treatment. The therapist says “I have several more nebulizer treatment to do on the unit where I am now. As soon as I’m finished, I’ll come and assess the client.” The nurse’s most appropriate action is to: 1. notify the primary physician immediately 2. stay with the client until the therapist arrive. 3. Administer the treatment by metered- dose inhaler. 4. give the nebulizer treatment herself.

4. give the nebulizer treatment herself. Rationale: The client’s needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the therapist lack of response after she administers the nebulizer.

300

A client with COPD presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn’t want to be placed not eh ventilator. What action should the nurse take? 1. Notify the physician immediately so he can determine client competency. 2. Have the client sign a DNR form. 3. Determine whether the client’s family was consulted about his decision. 4. Consult the palliative care group to direct care for the client.

1. Notify the physician immediately so he can determine client competency. Rationale: Three requirements for informed decision making: he decision must be given voluntarily, the client making the decision must have the capacity and competence to understand, and the client must be given adequate information to make the decision. In light of the client’s respiratory acidosis and hypoxemia, the chest might not be competent to make the decision. The physician should be notified immediately so he can determine client competency. The physician is responsible not the nurse to discuss with the client the implications of DNR order with the client.

400

A patient with asthma has the following arterial blood has results early in an acute asthma attack: pH 7.48, PaCO2 30mmHg, Pa02 78mmHg. What is the most appropriate action by the nurse? 1. Prepare the patient for mechanical ventilation 2. Have the patient breathe in a paper bag to raise the PaCO2 3. Document the finding and monitor the ABGs for a trend toward alkalosis 4. Reduce the patient's oxygen floe rate to keep the PaO2 at the current level

3. Document the finding and monitor the ABGs for a trend toward alkalosis Rationale: Early in an asthma attack, an increased respiratory rate and hyperventilation create a respiratory alkalosis with increased pH and decreased PaCO2, accompanied by hypoxemia. As the attack progresses, pH shifts to normal, then decreases, with ABGs that reflect respiratory acidosis with hypoxemia. During the attack, high-flow oxygen should be provided.

500

To decrease the patient's send of panic during an acute asmthma attack, what is the best action for the nurse to do? 1. Leave the patient alone to rest in a quiet calm, environment 2. Stay with the patient and encourage slow, pursed lip breathing 3. Reassure the patient that the attack can be controlled with treatment 4. Let the patient know that frequent monitoring is being done using measurement of vital signs and SpO2

2. Stay with the patient and encourage slow, pursed lip breathing Rationale: The patient in an acute asthma attack is very anxious and fearful. It is important to stay with the patient and interact in a calm, unhurried manner. Helping the patient to breathe with pursed lips will facilitate expiration of trapped air and help the patient gain control of breathing.