CHAPTER 33 - PHARM
The nurse has finished teaching a 15-year-old client how to use an inhaler to treat asthma. What statement by the client suggests an understanding of the teaching?
"I need to shake the inhaler well before taking the medication." EXPLANATION: Just before each use, the client should shake the inhaler well. After shaking, proper technique involves exhaling before placing the inhaler in the mouth; taking a slow, deep breath while delivering the medication into the mouth; and holding the breath for approximately ten seconds before exhaling slowly. A subsequent dose can be administered within a few minutes of the first.
A nurse is preparing to teach a client with asthma about the prescribed medication. The nurse will point out the increased risk of developing Candida albicans with which medication(s)? Select all that apply.
-Cromolyn -Fluticasone -Budesonide/formoterol Explanation: Mast cell aerosols such as cromolyn and inhaled corticosteroids (ICSs) such as fluticasone and budesonide/formoterol have been associated with the development of oral thrush. Therefore, the client needs instructions on how to reduce their risk. Albuterol, a short-acting beta2 agonist, and tiotropium, a cholinergic blocker, are not associated with the development of thrush.
When describing the mast cells to a group of students, an instructor would include what as being released by these cells? (Select all that apply.)
-Histamine -Serotonin -Adenosine triphosphate EXPLANATION: Mast cells release histamine, serotonin, adenosine triphosphate, and other chemicals to ensure a rapid and intense inflammatory reaction to any cell injury. Release of epinephrine and dopamine are not associated with mast cells.
The nurse teaches a client receiving an inhaled corticosteroid about the possibility of developing oral thrush. Which action(s) would the nurse include in the teaching plan as a way to reduce this risk? Select all that apply.
-Performing strict oral hygiene -Cleaning the inhaler per package instructions -Using proper technique when administering dose EXPLANATION: To decrease the likelihood of developing oral thrush, a client should use strict oral hygiene, cleanse the inhaler as directed in the package instructions, and use proper technique when administering a dose. There is no need to avoid eating after administration, and using the drug only every other day would not be effective.
The nurse is caring for a client experiencing an asthma attack. Which finding(s) will the nurse expect to assess in this client? Select all that apply.
-Wheezing -Chest tightness -Shortness of breath Explanation: Asthma is characterized by reversible bronchospasm, inflammation, and hyperactive airways. Symptoms of asthma include wheezing, chest tightness, and shortness of breath. Weight loss and a purulent productive cough are not symptoms associated with asthma.
A client with asthma has received two doses of theophylline. After analyzing the daily serum theophylline level, the nurse determines the client has achieved a therapeutic level with which result?
13 mcg/L Explanation: Therapeutic theophylline levels range from 10 to 20 mcg/L. The possibility of toxicity increases with levels over 15 mcg/L, with toxicity indicated with levels over 20 mcg/L.
During the summer, a female client experiences increased periods of acute symptoms of her asthma. The health care provider increases the dose frequency of which of her medications?
Albuterol Explanation: Albuterol is the initial drug of choice for acute bronchospasm.
After reviewing information about drugs used to treat lower respiratory system conditions, a group of nursing students demonstrate understanding of the information when they identify which as an example of a short-acting beta-2 agonist (SABA)?
Albuterol EXPLANATION: Albuterol is a SABA. Formoterol, salmeterol, and arformoterol are all long-acting beta-2 agonists.
A client is prescribed a leukotriene receptor antagonist. The nurse should evaluate the e!ectiveness of the medication therapy based on the long term management of symptoms associated with which respiratory condition?
Asthma Explanation: Leukotriene receptor antagonists block or antagonize receptors for the production of leukotrienes D4 and E4, thus blocking many of the signs and symptoms of asthma. This class of medication is not typically associated with the long term management of any of the other options.
A client is prescribed a leukotriene receptor antagonist. The nurse should evaluate the effectiveness of the medication therapy based on the long term management of symptoms associated with which respiratory condition?
Asthma Explanation: Leukotriene receptor antagonists block or antagonize receptors for the production of leukotrienes D4 and E4, thus blocking many of the signs and symptoms of asthma. This class of medication is not typically associated with the long term management of any of the other options.
A client is experiencing an acute asthmatic attack. Which agent would be most e!ective?
Beta-2 selective adrenergic agonist Explanation: A beta-2 selective adrenergic agonist or sympathomimetic would be most appropriate because these agents are rapidly distributed after injection and rapidly absorbed after inhalation. An inhaled steroid would require 2 to 3 weeks to reach e!ective levels. Leukotriene receptor
The nurse is developing an asthma plan for a young client and caregiver. The nurse determines they understand the plan when they correctly choose which actions to implement? Select all that apply.
Call health care provider is in yellow zone for more than 24 hours Quick-relief medications are not working EXPLANATION: The Asthma Care Plan utilizes the stop light approach with red, yellow, and green activities to guide the client in helping to maintain their control of asthma. Factors such as staying in the yellow zone for more than 24 hours and quick-relief medications not working are found in the red zone and necessitate an immediate call to the health care provider to advert a crisis. Waking up at night with wheezing, peak flow of 55% of personal best, and being able to only do some but not all usual activities are found in the yellow zone and should alert the client to take appropriate action to prevent the asthma from worsening..
A client is given theophylline to treat acute asthma symptoms. Which food should the client avoid?
Chocolate Explanation: Chocolate contains caffeine and is also a xanthine; thus chocolate should be avoided when the client is taking theophylline.
The nurse is caring for a client who is experiencing an attack of acute bronchiectasis. What is the principal pathologic finding in the diagnosis of bronchiectasis?
Chronic, irreversible dilation of the bronchi and bronchioles Explanation: Bronchiectasis is a chronic disease that involves the bronchi and bronchioles. It is characterized by dilation of the bronchial tree, chronic infection, and inflammation of the bronchial passages. It is not caused by increased red blood cell concentration in the blood, leakage of fluid into the alveolar interstitial spaces, or the obstruction of the pulmonary vasculature by a clot.
A nurse would expect to increase the dosage of theophylline if the client has a current history of which of the following?
Cigarette smoking EXPLANATION: Nicotine increases the metabolism of xanthines; therefore, an increased dosage would be necessary. Hyperthyroidism, gastrointestinal, upset or alcohol intake requires cautious use of the drug because these conditions may be exacerbated by the systemic e!ects of the drug. The drug dosage may need to be decreased in these situations.
A nurse is providing discharge planning for a 45-year-old woman who has a prescription for oral albuterol. The nurse will question the patient about her intake of which of the following?
Coffee Explanation: The nurse should assess the patient's intake of caffeine, including coffee, tea, soda, cocoa, candy, and chocolate. Caffeine has sympathomimetic effects that may increase the risk for adverse effects. Alcohol, salt, and vitamin C intake is important to assess, but does not potentiate the effects of albuterol.
Shane, a 25-year-old man, is diagnosed with asthma. He began an albuterol MDI 2 weeks ago. He reports that his symptoms persist in spite of using albuterol MDI as prescribed. What advice should the nurse give the client?
Contact the health care provider to obtain adjunctive medications. Explanation: Explain to the client the importance of administering the drug as prescribed and encourage consultation with the health care provider if the symptoms do not abate with the recommended therapy. Using the MDI more frequently than recommended can result in rebound bronchoconstriction, which may motivate the client to increase MDI use, stimulating the cycle of rebound. This practice is not recommended.
A group of students are reviewing the various drugs that affect inflammation. The students demonstrate understanding when they identify which agent as a mast cell stabilizer?
Cromolyn EXPLANATION:: Cromolyn is a mast cell stabilizer. Montelukast is a leukotriene receptor antagonist. Calfactant is a lung surfactant. Triamcinolone is an inhaled steroid.
A client who has been admitted to the healthcare center has been diagnosed with emphysema. The arterial blood gas results reveal respiratory acidosis. Based on this information, what should the nurse explain to the client that is the cause of the respiratory acidosis?
Excess carbon dioxide in the blood EXPLANATION: If a person has a breathing disorder, carbon dioxide can build up in the body, dangerously lowering the blood pH. This condition, called respiratory acidosis, can be caused by disorders, such as emphysema, severe pneumonia, asthma, and pulmonary edema. Too little carbon dioxide in the blood is called respiratory alkalosis. Coughing and sneezing are protective reflexes needed to dislodge materials from the respiratory passages. Pleurisy is an inflammation of the pleura caused by infection, injury, or tumor.
A nurse is providing health education to a client recently diagnosed with asthma and prescribed albuterol and ipratropium. Which of the client's statements suggests a need for clarification by the nurse?
I'll keep taking my medications until I'm not experiencing any more symptoms." Explanation: Antiasthma medications should normally be taken on a regular schedule, not solely based on immediate symptoms. They should not be discontinued in the absence of symptoms. Increasing fluid intake, limiting caffeine, and adhering to the administration schedule are correct actions.
A nurse is providing health education to a client recently diagnosed with asthma and prescribed albuterol and ipratropium. Which of the client's statements suggests a need for clarification by the nurse?
I'll keep taking my medications until I'm not experiencing any more symptoms." EXPLANATION: Antiasthma medications should normally be taken on a regular schedule, not solely based on immediate symptoms. They should not be discontinued in the absence of symptoms. Increasing fluid intake, limiting caffiine, and adhering to the administration schedule are correct actions.
The nurse is reviewing a client's morning blood work and notes a theophylline level of 22.2 mcg/mL (123.21 µmol/L). What action should the nurse take?
Inform the health care provider that the client has toxic theophylline levels. Explanation: To determine theophylline dosage, prescribers should measure serum theophylline levels. Therapeutic range is 5 to 15 mcg/mL (27.75 to 83.25 µmol/L); toxic levels are 20 mcg/mL (111 µmol/L) or above. The health care provider must be informed of this elevated serum level.
What is the most effective method used to monitor clients with asthma that they can use at home?
Peak-flow monitor Explanation: A specific monitoring plan for clients with asthma should be in place, whether through peak-flow or symptom monitoring.
A nurse is caring for a client with chronic bronchiectasis. The nurse should assess the patient for which clinical manifestation?
Purulent cough
A client receiving aminophylline reports heartburn on assessment to the nurse. What is the best response by the nurse?
Raise the head of the bed. Explanation: When a client receiving aminophylline reports heartburn, the nurse should instruct the client to remain upright with the head end of the bed raised. Eating small, frequent meals and limiting fluid intake with meals help alleviate the symptoms of nausea, and not of heartburn. Using strict oral hygiene helps prevent infection with Candida albicans seen with corticosteroid therapy.
A client receiving aminophylline reports heartburn on assessment to the nurse. What is the bestresponse by the nurse?
Raise the head of the bed. Explanation: When a client receiving aminophylline reports heartburn, the nurse should instruct the client to remain upright with the head end of the bed raised. Eating small, frequent meals and limiting fluid intake with meals help alleviate the symptoms of nausea, and not of heartburn. Using strict oral hygiene helps prevent infection with Candida albicans seen with corticosteroid therapy.
The nurse is evaluating the education of a client that uses albuterol for an acute asthma attack. The nurse knows that the lesson has been effective when the client states that albuterol is which of the following types of medication?
SABA Explanation: Albuterol is a short-acting beta-2 agonist (SABA). It is used to treat and prevent bronchospasm.
The health care provider has ordered epinephrine for a client admitted emergently with bronchospasms. The nurse will prepare to administer this drug via which route?
Subcutaneous Explanation: The nurse should use the subcutaneous route to administer epinephrine for acute bronchospasm. The other routes are not appropriate for this situation.
The nurse is caring for a 38-year-old client who is beginning treatment with albuterol. Which should the nurse identify as a potential adverse effect of the drug?
Tachycardia EXPLANATION: Adverse e!ects of adrenergic bronchodilators such as albuterol include tachycardia, arrhythmias, palpitations, restlessness, agitation, and insomnia. Bronchodilators do not cause polydipsia, nausea or diarrhea.
The nurse is caring for a 38-year-old client who is beginning treatment with albuterol. Which should the nurse identify as a potential adverse e!ect of the drug?
Tachycardia Explanation: Adverse e!ects of adrenergic bronchodilators such as albuterol include tachycardia, arrhythmias, palpitations, restlessness, agitation, and insomnia. Bronchodilators do not cause polydipsia, nausea or diarrhea.
What action by the client would indicate to the nurse that the client understands how to use an inhaler?
The client holds their breath as long as possible after depressing the canister. EXPLANATION: Holding the breath prevents exhalation of medication still remaining in the mouth. The client should inhale when the canister is depressed, not as soon as the inhaler enters the mouth. The client should only administer one dose of medication at a time, and the client should wait to exhale until after the breath has been held as long as possible. Spacers are not used with powdered medications.
The nurse is caring for a 38-year-old client who has been diagnosed with asthma and is prescribed albuterol. What assessment finding should the nurse most likely attribute to adverse medication effects?
The client's heart rate is 99 beats/min. Explanation: Adverse effects of these drugs, which can be attributed to sympathomimetic stimulation, include central nervous system (CNS) stimulation, gastrointestinal upset, cardiac arrhythmias, hypertension, angina, sweating, pallor, and flushing. Adrenergic agents do not cause polydipsia, fever, or diarrhea.
Why are inhaled steroids used to treat asthma and COPD?
They act locally to decrease release of inflammatory mediators Explanation: When administered into the lungs by inhalation, steroids decrease the effectiveness of the inflammatory cells. This has two effects, which are decreased swelling associated with inflammation and promotion of beta-adrenergic receptor activity, that may promote smooth muscle relaxation and inhibit bronchoconstriction.
A male client is concerned because ever since he began his antiasthma medication, his GERD symptoms are worse. The nurse explains that his symptoms are worse because his asthma medications have what effect?
They relax the gastresophageal sphincter. Explanation: Asthma may aggravate GERD, because antiasthma medications that dilate the airways also relax muscle tone in the gastresophageal sphincter and may increase acid reflux.
Respiratory symptoms are treated with many types of drugs, including
anti-inflammatory agents. Explanation: Major drug groups used to treat respiratory symptoms are bronchodilating and anti-inflammatory agents, antihistamines, and nasal decongestants, antitussives, and cold remedies.
A client who is immunosuppressed reports malaise, myalgias, and a purulent productive cough. For which condition would the nurse plan care for this client?
bronchiectasis EXPLANATION: Bronchiectasis is a chronic disease that involves the bronchi and bronchioles. It is characterized by dilation of the bronchial tree and chronic infection and inflammation of the bronchial passages. Clients with bronchiectasis often have an underlying medical condition that makes them more susceptible to infections such as immune suppression. Signs and symptoms of acute infection associated with bronchiectasis include a fever, malaise, myalgia, arthralgia, and a purulent, productive cough. The client's symptoms are not associated with atelectasis, pneumonia, or tuberculosis.
What pathology is present in a client diagnosed with chronic asthma even when they may appear symptom free? Select all that apply.
damaged airway mucosa airway inflammation EXPLANATION: Inflammation and damaged airway mucosa are chronically present in asthma, even when clients appear symptom free. None of the other options are associated with chronic asthma.
A nurse is providing education to a 56-year-old man who is admitted to the emergency department with an acute asthma attack. The nurse's initial assessment reveals that the patient has a history of pneumonia, drinks large quantities of coffee, and eats a high-calorie diet. Albuterol is prescribed for him. The important consideration when the nurse is preparing a teaching plan will be that the patient
has a high coffee intake. Explanation: Caffeine has sympathomimetic effects that may increase the risk for adverse e!ects with albuterol. The nurse should assess the patient's intake of ca!eine through co!ee, tea, soda, cocoa, candy, and chocolate. The patient's age, history of pneumonia, and preference for high- calorie food would not have important implications for his albuterol drug therapy.
The nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). The plan of care will focus on which client problem?
lack of patent airway EXPLANATION: Asthma, emphysema, COPD, and respiratory distress syndrome (RDS) are pulmonary obstructive diseases. All but RDS involve obstruction of the major airways. RDS obstructs the alveoli. Pain, activity intolerance, and adverse e!ects of medication therapy are conditions identified to detect, manage, and minimize unexpected outcomes. The nurse should be especially aware of the potential for an obstructed airway in these clients.
A client recovering from surgery has reduced lung sounds and hypoxia from atelectasis. Which treatment will the nurse expect to be prescribed for this client?
oxygen therapy Explanation: Atelectasis is the incomplete expansion of alveoli that can develop after surgery, pain, decreased coughing, and accumulation of secretions in the lower airways. Treatment involves actions to clear the airways, delivering oxygen, and assisting ventilation. Antibiotics, ambulation, and decongestants are not used to treat atelectasis.
A 70-year-old client is being treated for chronic obstructive pulmonary disease (COPD) with theophylline. What will be a priority assessment by the nurse?
use of nicotine Explanation: Nutritional status, weight, and activity level would be important for a nurse to know about a COPD client. However, it would be most important for the nurse to know whether the client smokes or uses tobacco in other ways, or smoking cessation methods that involve nicotine. Nicotine increases the metabolism of theophyllines; the dosage may need to be increased to produce a therapeutic effect.
