Chapter 24: Management of Patients with Chronic Pulmonary Disease

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis Rationale: In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Respiratory rate of 22 breaths/minute Dilated and reactive pupils Urine output of 40 ml/hour Heart rate of 100 beats/minute

Respiratory rate of 22 breaths/minute Rationale: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he: sits in tripod position. has a pulse oximetry reading of 93%. uses the sternocleidomastoid muscles. wants the head of the bed raised to a 90-degree level.

uses the sternocleidomastoid muscles. Rationale: Use of accessory muscles indicates worsening breathing conditions. Assuming the tripod position, a 93% pulse oximetry reading, and a request for the nurse to raise the head of the bed don't indicate that the client's condition is worsening.

The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction? "Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." "I can't use a spacer or holding chamber with the MDI." "I will take a slow, deep breath in after pushing down on the MDI." "I will shake the MDI container before I use it."

"I can't use a spacer or holding chamber with the MDI." Rationale: The client can use a spacer or a holding chamber to facilitate the ease of medication administration. The remaining client statements are accurate and indicate the client understands how to use the MDI correctly.

Which statement describes emphysema? A disease of the airways characterized by destruction of the walls of overdistended alveoli A disease that results in reversible airflow obstruction, a common clinical outcome Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years Chronic dilatation of a bronchus or bronchi

A disease of the airways characterized by destruction of the walls of overdistended alveoli Rationale: Emphysema is a category of COPD. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

What are the primary causes for an acute exacerbation of COPD? Select all that apply. Air pollution Tracheobronchial infection Change in season from spring to summer Gastrointestinal viruses Hypertension

Air pollution Tracheobronchial infection Rationale: Common causes of an acute exacerbation include tracheobronchial infection and air pollution. However, the cause of approximately one third of severe exacerbations cannot be identified. Change in season from spring to summer, hypertension, and GI viruses are not causes of exacerbation of COPD. Winter is worse for COPD when viral and bacterial infections are more prevalent.

A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed? Ipratropium bromide Fluticasone propionate Ipratropium bromide and albuterol sulfate Albuterol

Albuterol Rationale: Albuterol (Proventil), a SABA, is given to asthmatic patients for quick relief of symptoms. Ipratropium bromide (Atrovent) is an anticholinergic. Ipratropium bromide and albuterol sulfate (Combivent) is a combination SABA/anticholinergic, and Fluticasone propionate (Flonase) is a corticosteroid.

A 55-year-old client is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse Asks the client, "What are your allergies?" Explains to the client not to eat or drink before the spirometry test States that various blood tests must also be done Tells the client that arterial blood gas is performed after spirometry testing

Asks the client, "What are your allergies?" Rationale: Spirometry testing includes use of a bronchodilator and then further testing. The nurse needs to assess for allergies first. The client does not need to be NPO prior to spirometry testing. Venous blood work may be done for clients younger than 45 years old, to check for a deficiency in alpha 1-antitrypsin. Arterial blood gases, if ordered, are obtained prior to spirometry testing.

A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take? Aspirates for blood return before injecting the medication Assesses fasting blood glucose levels Encourages the client to decrease caloric intake due to increased appetite Informs the client to limit fluid intake due to fluid retention

Assesses fasting blood glucose levels Rationale: Adverse effects of methylprednisolone (Solu-Medrol) include abnormalities in glucose metabolism. The nurse monitors blood glucose levels. Methylprednisolone also increases the client's appetite and fluid retention, but the client will not decrease caloric or fluid intake as a result of these adverse effects. It is not necessary to aspirate for blood return prior to injecting the medication, because doing so would not support the intravenous line in the vein.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for? Atelectasis Emphysema Pleurisy Pneumonia

Atelectasis Rationale: In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take? Encourage the client to take deep breaths. Encourage the client to exhale slowly against pursed lips. Teach the client to perform upper chest breaths. Increase the flow of oxygen.

Encourage the client to exhale slowly against pursed lips. Rationale: When a client with COPD exhibits shallow, rapid, and inefficient respirations, the nurse encourages the client to perform pursed-lip breathing, which includes exhaling slowly against pursed lips. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps the client control the rate and depth of respiration. It also promotes relaxation, enabling the client to gain control of dyspnea and reduce feelings of panic. Taking deep breaths and upper chest breathing are inefficient breathing techniques; the client with COPD should be encouraged to practice diaphragmatic breathing. Increasing oxygen flow is not necessary because the pulse oximetry is 93%.

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client Has wheezes in the right lung lobes Has a respiratory rate of 28 breaths/minute Reports shortness of breath Cannot perform activities of daily living

Has wheezes in the right lung lobes Rationale: Of the data listed, wheezing, an adventitious lung sound, is the best datum that supports the diagnosis of ineffective airway clearance. An increased respiratory rate and a report of dyspnea are also defining characteristics of this nursing diagnosis. They could support other nursing diagnoses, as would inability to perform activities of daily living.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? Full-liquid High-protein 1,800-calorie ADA Low-fat

High-protein Rationale: Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

Asthma is cause by which type of response? IgD-mediated IgM-mediated IgE-mediated IgA-mediated

IgE-mediated Rationale: Atopy, the genetic predisposition for the development of an IgE-mediated response to allergens, is the most common identifiable predisposing factor for asthma. Chronic exposure to airway allergens may sensitize IgE antibodies and the cells of the airway.

Which measure may increase complications for a client with COPD? Administration of antibiotics Increased oxygen supply Administration of antitussive agents Decreased oxygen supply

Increased oxygen supply Rationale: Administering too much oxygen can result in the retention of carbon dioxide. Clients with alveolar hypoventilation cannot increase ventilation to adjust for this increased load, and hypercapnia occurs. All the other measures aim to prevent complications.

The client is prescribed albuterol 2 puffs as a metered-dose inhaler. Which action by the client demonstrates understanding of administration for this medication? Positions the inhaler 2 finger widths away from the lips Carefully holds the inhaler upright without shaking it Holds the breath for 5 seconds after administering the medication Immediately repeats the second puff after the first puff

Positions the inhaler 2 finger widths away from the lips Rationale: To administer a metered-dose inhaler, the client holds the inhaler upright and shakes the inhaler. The inhaler is positioned 2 finger widths away from lips. After administering the medication, the client holds the breath for as long as possible, at least 10 seconds. The client may administer the next puff in 15 to 30 seconds.

A client with asthma has developed obstruction of the airway. Which of the following does the nurse understand as having potentially contributed to this problem? Choose all that apply. Thick mucus Swelling of bronchial membranes Destruction of the alveolar wall Airway remodeling

Swelling of bronchial membranes Thick mucus Airway remodeling Rationale: As asthma becomes more persistent, inflammation progresses and airway edema, mucus hypersecretion, and formation of mucus plugs can occur. Airway remodeling may occur in response to chronic inflammation, causing further airway narrowing. Destruction of the alveolar wall does not occur with asthma.

A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time. Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is necessary? "I will make sure to take a slow, deep breath as I push on my inhaler." "After I breathe in, I will hold my breath for 10 seconds." "I do not need to rinse my mouth with this type of inhaler." "If I use the spacer, I know I am only supposed to push on the inhaler once."

"I do not need to rinse my mouth with this type of inhaler." Rationale: Mouth-washing and spitting are effective in reducing the amount of drug swallowed and absorbed systemically. Actuation during a slow (30 L/min or 3 to 5 seconds) and deep inhalation should be followed by 10 seconds of holding the breath. The client should actuate only once. Simple tubes do not obviate the spacer/VHC per inhalation.

Which is the strongest predisposing factor for asthma? Congenital malformations Allergy Male gender Air pollution

Allergy Rationale: Allergy is the strongest predisposing factor for asthma.

Which statement describes emphysema? A disease of the airways characterized by destruction of the walls of overdistended alveoli A disease that results in reversible airflow obstruction, a common clinical outcome Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years Chronic dilatation of a bronchus or bronchi

A disease of the airways characterized by destruction of the walls of overdistended alveoli Rationale: Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of alveoli; a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

Which of the following is accurate regarding status asthmaticus? A severe asthma episode that is refractory to initial therapy Patients have a productive cough. Usually occurs with warning Usually does not progress to severe obstruction

A severe asthma episode that is refractory to initial therapy Rationale: Status asthmaticus is a severe asthma episode that is refractory to initial therapy. It is a medical emergency. Patients report rapid progressive chest tightness, wheezing, dry cough, and shortness of breath. It may occur with little or no warning.

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs? Administer the triamcinolone and then administer the salmeterol. Administer the salmeterol and then administer the triamcinolone. Allow the client to choose the order in which the drugs are administered. Monitor the client's theophylline level before administering the medications.

Administer the salmeterol and then administer the triamcinolone. Rationale: A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone (Azmacort) is a corticosteroid; Salmeterol (Serevent) is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

Which statement is true about both lung transplant and bullectomy? Both procedures cure COPD. Both procedures treat end-stage emphysema. Both procedures treat patients with bullous emphysema. Both procedures improve the overall quality of life of a client with COPD.

Both procedures improve the overall quality of life of a client with COPD. Rationale: Treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat clients with bullous emphysema.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis? Anxiety Imbalanced nutrition: More than body requirements Impaired swallowing Unilateral neglect

Anxiety Rationale: In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 65% for a patient with COPD. What stage should the nurse document the patient is in? I II III IV

II Rationale: All grades of COPD are associated with an FEV1/FVC ratio of less than 70%. Grade I (mild) is associated with an FEV1 of greater than or equal to 80%. Grade II (moderate) is associated with an FEV1 of 50%-80%. Grade III is associated with an FEV1 of <30%-50%. Grade IV is associated with an FEV1 of <30%.

A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action? Move the indicator to the top of the numbered scale. Sit down while completing a peak flow reading. Take and record peak flow readings three times daily. If coughing occurs during the procedure, repeat it.

If coughing occurs during the procedure, repeat it. Rationale: Steps for using the peak flow meter correctly include (1) moving the indicator to the bottom of the numbered scale; (2) standing up; (3) taking a deep breath and filling the lungs completely; (4) placing the mouthpiece in the mouth and closing the lips around it; (5) blowing out hard and fast with a single blow; and (6) recording the number achieved on the indicator. If the client coughs or a mistake is made in the process, repeat the procedure. Peak flow readings should be taken during an asthma attack.

A client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client includes teaching the family how to perform postural drainage. instructing the client on the signs of respiratory infection. implementing measures to clear pulmonary secretions. providing the client a low-calorie, high-fiber diet.

implementing measures to clear pulmonary secretions. Rationale: Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Although teaching the family how to perform postural drainage and instructing the client on the signs of respiratory infection are important, they are not the nurse's primary focus. The presence of a large amount of mucus may decrease the client's appetite and result in inadequate dietary intake; therefore, the client's nutritional status is assessed and strategies are implemented to ensure an adequate diet.