Chapter 24: Management of Patients with Chronic Pulmonary Disease

The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient would the nurse assess first?

An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office Explanation: On the patient's arrival at the emergency department, the first line of treatment is supplemental oxygen therapy and rapid assessment to determine if the exacerbation is life-threatening. Pulse oximetry is helpful in assessing response to therapy but does not assess PaCO2 levels. The fluids will not run out during the very beginning of the shift. The vital signs listed are normal findings for patients with COPD.

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

A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive treatment is indicated. What is the first action by the nurse?

Collects sputum for culture and sensitivity Explanation: Aggressive therapy for cystic fibrosis involves airway clearance and antibiotics, such as vancomycin and tobramycin, which will be prescribed based on sputum cultures. Sputum must be obtained prior to antibiotic therapy so results will not be skewed. Administering oral pancreatic enzymes with meals will be a lesser priority.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply.

Compromised gas exchange Decreased airflow Wheezes Explanation: Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2015).

A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations?

Cromolyn sodium Explanation: Cromolyn sodium is contraindicated in clients with acute asthma exacerbation. Indications for cromolyn sodium are long-term prevention of symptoms in mild, persistent asthma; it may modify inflammation. Cromolyn sodium is also a preventive treatment before exposure to exercise or a known allergen. Albuterol, levalbuterol HFA, and ipratropium can be used to relieve acute symptoms.

In which grade of COPD is the forced expiratory volume in 1 second (FEV1) less than 30% predicted?

IV Explanation: COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate): FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC <70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70% and FEV1 <30% predicted.

Which measure may increase complications for a client with COPD?

Increased oxygen supply Explanation: 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.

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?

Lung sounds Explanation: A client with COPD is at risk for developing pneumothorax. The description given is consistent with possible pneumothorax. Though the nurse will assess all the data, auscultating the lung sounds will provide the nurse with the information if the client has a pneumothorax.

The nurse is assigned to care for a patient in the ICU who is diagnosed with status asthmaticus. Why does the nurse include fluid intake as being an important aspect of the plan of care? (Select all that apply.)

To combat dehydration To loosen secretions To facilitate expectoration Explanation: The nurse also assesses the patient's skin turgor for signs of dehydration. Fluid intake is essential to combat dehydration, to loosen secretions, and to facilitate expectoration.

A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute 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 treatments 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:

give the nebulizer treatment herself. Explanation: The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the respiratory therapist's lack of response after the client's condition is stabilized. There is no need to involve the physician in personnel issues. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment not a metered-dose inhaler, so the nurse can't change the route without a new order from the physician.

A client is prescribed methylprednisolone (Solu-Medrol) 125 mg intravenously. The medication is available in a 125 mg single-dose vial containing 2 mL. The nurse will administer methylprednisolone over 2 minutes. How many mL will the nurse administer each 15 seconds? Write your answer to 2 decimal places. Starting with 0., enter the correct number ONLY.

0.25 Explanation: The volume to be infused is 2 mL over 2 minutes. There are 60 seconds in each minute. For every 15 seconds, the nurse will administer 0.25 mL. 2 mL/120 sec = x/15 sec. 0.25 mL = x

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?

Albuterol Explanation: 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.

Which of the following is a common irritant that acts as a trigger of asthma?

Esophageal reflux Explanation: Esophageal reflux, viral respiratory infections, cigarette smoke, and exercise are all irritants that can trigger asthma. Peanuts, aspirin sensitivity, and molds are antigens

The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client

Exhales hard and fast with a single blow Explanation: To use a peak flow meter, the client stands. Then the client takes a deep breath and exhales hard and fast with a single blow. The client repeats this twice and records a "personal best" in an asthma diary.

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 40% for a patient with COPD. What stage should the nurse document the patient is in?

III Explanation: 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%.

Which of the following is the key underlying feature of asthma?

Inflammation Explanation: Inflammation is the key underlying feature and leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheeze, and dyspnea.

A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is:

Sharp, stabbing chest pain Explanation: The initial symptom is usually chest pain of sudden onset that leads to feelings of chest pressure, dyspnea, and tachycardia. A cough may be present.

The nurse is instructing the patient with asthma in the use of a newly prescribed leukotriene receptor antagonist. What should the nurse be sure to include in the education?

The patient should take the medication an hour before meals or 2 hours after a meal. Explanation: The nurse should instruct the patient to take the leukotriene receptor antagonist at least 1 hour before meals or 2 hours after meals.

A commonly prescribed methylxanthine used as a bronchodilator is which of the following?

Theophylline Explanation: Theophylline is an example of a methylxanthine. All the others are examples of inhaled short-acting beta2 agonists.

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 Airway remodeling Explanation: 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.

The classification of Stage III of COPD is defined a

severe COPD. Explanation: Stage III is severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage IV is very severe COPD.

A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include

the importance of blood tests to monitor serum concentrations. Explanation: The nurse should inform clients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The client is at risk of developing hypokalemia.

The classification of Stage IV of COPD is defined as

very severe COPD. Explanation: Stage IV is very severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage III is severe COPD.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue?

"Delay self-care activities for 1 hour." Explanation: Some clients with COPD have shortness of breath and fatigue in the morning on arising as a result of bronchial secretions. Planning self-care activities around this time may be better tolerated by the client, such as delaying activities until the client is less short of breath or fatigued. The client raising the arms over the head may increase dyspnea and fatigue. Sitting in a chair when bathing or dressing will aid in dyspnea and fatigue but does not address the situation upon arising. Drinking fluids will assist in liquifying secretions which, thus, will aid in breathing, but again does not address the situation in the morning.

Which medication is contraindicated in acute asthma exacerbations?

Cromolyn sodium Explanation: Cromolyn sodium is contraindicated in clients with acute asthma exacerbation.

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 do not need to rinse my mouth with this type of inhaler." Explanation: 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.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

An inhaled beta2-adrenergic agonist Explanation: An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects. The I.V. form is typically used when the inhaled beta2-adrenergic agonist doesn't work. A corticosteroid is slow acting, so its use won't reduce hypoxia in the acute phase.

A client with chronic obstructive pulmonary disease (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?

An inspiratory-expiratory (I:E) ratio of 2:1 Explanation: The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration. A client with COPD typically has a barrel chest in which the anteroposterior diameter is larger than the transverse chest diameter. A client with COPD usually has a respiratory rate greater than 12 breaths/minute and an oxygen saturation rate below 93%.

A client with asthma is being treated with albuterol. Which of the findings from the client's history would indicate to the nurse the need to administer this drug with caution?

Angina Explanation: Patients, especially older adults, with pre-existing cardiovascular disease may have adverse cardiovascular reactions with inhaled therapy. Albuterol (Proventil) does not increase the secretions of the GI tract or cause gastric irritation. It will not worsen a peptic ulcer.

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 Explanation: 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 is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

It helps prevent early airway collapse. Explanation: Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply.

Prevent airway collapse Control the rate and depth of respirations Release air trapped in the lungs Explanation: The nurse is teaching the client the technique of pursed-lip breathing. It helps slow expiration, prevents collapse of the airways, releases air trapped in the lungs, and helps the client control the rate and depth of respirations. This helps clients relax and get control of dyspnea and reduces the feelings of panic they may experience. Diaphragmatic breathing strengthens the diaphragm during breathing. In inspiratory muscle training, the client will be instructed to inhale against a set resistance for a prescribed amount of time every day in order to condition the inspiratory muscles.

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment?

Providing sufficient oxygen to improve oxygenation Explanation: The main objective in treating patients with hypoxemia and hypercapnia is to give sufficient oxygen to improve oxygenation.

A client has been classified as status asthmaticus. The nurse understands that this client will likely initially exhibit symptoms of:

Respiratory alkalosis Explanation: There is a reduced PaCO2 and initial respiratory alkalosis, with a decreased PaCO2 and an increased pH. As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

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?

II Explanation: 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 experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take?

Assesses fasting blood glucose levels Explanation: 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.

Which of the following occupy space in the thorax, but do not contribute to ventilation?

Bullae Explanation: Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax. Bullae may compress areas of healthier lung and impair gas exchange. Alveoli are the functional units of the lungs. Lung parenchyma is lung tissue. Mast cells, when activated, release several chemicals called mediators that include histamine, bradykinin, prostaglandins, and leukotrienes.

Asthma is cause by which type of response?

IgE-mediated Explanation: 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.

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?

Ineffective coping related to anxiety Explanation: Any factor that interferes with normal breathing quite naturally induces anxiety, depression, and changes in behavior. Constant shortness of breath and fatigue may make the patient irritable and apprehensive to the point of panic. Although the other choices are correct, the most important psychosocial nursing diagnosis for a patient with COPD is ineffective coping related to a high level of anxiety.

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply.

Inflamed airways that obstruct airflow Mucus secretions that block airways Overinflated alveoli that impair gas exchange Explanation: Because of chronic inflammation and the body's attempts to repair it, changes and narrowing occur in the airways. In the proximal airways, changes include increased numbers of goblet cells and enlarged submucosal glands, both of which lead to hypersecretion of mucus. In the peripheral airways, inflammation causes thickening of the airway wall, peribronchial fibrosis, exudate in the airway, and overall airway narrowing.

Cystic fibrosis (CF) is diagnosed by clinical signs and symptoms in addition to which test?

Sweat chloride concentration Explanation: Diagnosis of CF is based on an elevated sweat chloride concentration, together with clinical signs and symptoms consistent with the disease.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

Using a Venturi mask to deliver oxygen as ordered Explanation: The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.

A cient with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed?

With meals Explanation: Nearly 90% of clients with cystic fibrosis have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis. Explanation: In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

Which diagnostic test is most accurate in assessing acute airway obstruction?

Pulmonary function studies Explanation: Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression. ABGs and pulse oximetry are not the most accurate diagnostics for an airway obstruction. Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of FEV1 to forced vital capacity (FVC).

The nurse is caring for a patient with status asthmaticus in the intensive care unit (ICU). What does the nurse anticipate observing for the blood gas results related to hyperventilation for this patient?

Respiratory alkalosis Explanation: Respiratory alkalosis (low PaCO2) is the most common finding in patients with an ongoing asthma exacerbation and is due to hyperventilation.

A physician orders metaproterenol by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?

"I need to hold my breath as long as possible after I take a deep inhalation." Explanation: The client demonstrates effective teaching if he states that he'll hold his breath for as long as possible after inhaling the drug. Holding the breath increases the absorption of the drug into the alveoli. Metaproterenol (Alupent) needs to be used over an extended period for maximum effect. The client shouldn't use the inhaler whenever he feels out of breath because dependency can develop if the drug is used excessively. The client should adhere to the prescribed dosage. Tachycardia is an expected adverse reaction to metaproterenol. The client should be taught how to monitor his heart rate and contact the physician only if the heart rate exceeds 130 beats/minute.