RESPIRATORY PREPU 23&24

The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction?

"I can't use a spacer or holding chamber with the MDI." Explanation: 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.

Arterial blood gas analysis would reveal which value related to acute respiratory failure?

pH 7.28 Explanation: Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

"I make sure my oxygen mask is on tightly so it won't fall off while I nap." Explanation: The client requires additional teaching if he states that he fits his mask tightly. Applying the oxygen mask too tightly can cause skin breakdown, so the client should be cautioned against wearing it too tightly. Oxygen therapy is drying to the oral and nasal mucosa; therefore, the client should be encouraged to apply a water-soluble lubricant, such as K-Y jelly, to prevent drying. Smoking is contraindicated wherever oxygen is in use; posting of a "no smoking" sign warns people against smoking in the client's house. Cleaning the mask with water two or three times per day removes secretions and decreases the risk of infection.

A client newly diagnosed with COPD tells the nurse, "I can't believe I have COPD; I only had a cough. Are there other symptoms I should know about"? Which is the best response by the nurse?

"Other symptoms you may develop are shortness of breath upon exertion and sputum production." Explanation: COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea upon exertion. Clients with COPD are at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk of acute and chronic respiratory failure. Weight loss is common with COPD.

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range?

2.0 to 2.5 Low-molecular- weight heparin and fondaparinux (Arixtra) are the cornerstones of therapy, but IV unfractionated heparin may be used during the initial phase (ACCP, 2012). The early maintenance phase of anticoagulation typically consists of overlapping regimens of heparins or fondaparinux for at least 5 days with an oral vitamin K antagonist (e.g., warfarin [Coumadin]). A 3- to 6-month regimen of long-term maintenance with warfarin is typical but depends on the risks of recurrence and bleeding (ACCP, 2012). Heparin must be continued until the INR is within a therapeutic range, typically 2.0 to 3 (Kearon, Kahn, Agnelli, et al., 2008).

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered. Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client re-inhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

A client is being treated in the ED for respiratory distress coupled with bacterial pneumonia. The client has no medical history. However, the client works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which order based on the client's immediate needs?

Administration of antibiotics Explanation: Antibiotics are administered to treat respiratory tract infections. Chronic bronchitis is inflammation of the bronchi caused by irritants or infection. Hence, smoking cessation and avoiding pollutants are necessary to slow the accelerated decline of the lung tissue. However, the immediate priority in this case is to cure the infection, pneumonia. Corticosteroids and bronchodilators are administered to asthmatic clients when they show symptoms of wheezing. An ECG is used to evaluate atrial arrhythmias.

A nurse is teaching a client about bronchodilators. What bronchodilator actions that relieve bronchospasm should the nurse include in the client teaching? Select all that apply.

Alter smooth muscle tone Reduce airway obstruction Increase oxygen distribution Explanation: Bronchodilators relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation. Inflammation would be reduced by corticosteroids.

The nurse is providing discharge teaching for a client who developed a pulmonary embolism after total knee surgery. The client has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client?

Anticoagulant therapy usually lasts between 3 and 6 months. Explanation: Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.

A nurse is assigned to a client diagnosed with emphysema. In prioritizing the care for the shift, which intervention should the nurse choose first?

Apply oxygen therapy as ordered. Explanation: Oxygen will correct the hypoxemia. Careful observation of the liter flow or the percentage administered and its effect on the patient is important. These clients generally require low flow oxygen rates of 1-2 L/min. Monitor and titrate to achieve desired PaO2. Periodic arterial blood gases and pulse oximetry help evaluate adequacy of oxygenation. The priority action is not referral to the respiratory therapist. Vital signs monitoring is important, but not the first action. Education is part of the shift, but not the priority.

A client's spouse states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. What findings would indicate a need for further interventions?

BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C) Explanation: Bronchopulmonary infections must be controlled to diminish inflammatory edema and to permit recovery of normal ciliary action. Minor respiratory infections of no consequence to people with normal lungs can be life-threatening to people with COPD. The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. Any factor that interferes with normal breathing quite naturally induces anxiety, depression, and changes in behavior.

A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply.

Chest tightness Wheezing Cough Explanation: 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 teaching a client about asthma. What symptoms should be included with the teaching? Select all that apply.

Chest tightness Wheezing Dyspnea Productive cough Explanation: The common symptoms of asthma are productive cough, chest tightness, dyspnea, and wheezing. In some instances, cough may be the only symptom. Crackles are not seen with clients with asthma.

A nurse is admitting a client with emphysema. What are presenting findings the nurse should assess? Select all that apply.

Chronic cough Dyspnea Explanation: The clinical manifestations for emphysema is grouped with COPD and includes chronic cough, sputum production, and dyspnea. Chest pain, wheezing, and tachypnea are not common findings.

Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)?

Cigarette smoking Explanation: Pipe, cigar, and other types of tobacco smoking are also risk factors for COPD. Although risk factors, neither occupational exposure nor air pollution is the most important risk factor for development of COPD. Genetic abnormalities are also a risk factor, but again, not the most important one.

A clinic nurse is caring for a client who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse what he could have done to minimize the risk of contracting this disease. What should the nurse describe as the most significant risk factor?

Cigarette smoking Explanation: The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process?

Consolidation Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. You Selected:

Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a "pumping" exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.

A nurse is caring for a client with COPD. The client's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. Therapeutic effects of this medication would include which of the following? Select all that apply.

Increased expiratory flow rate Relief of dyspnea Explanation: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the client's respiratory status. Bronchodilators would not have a direct result on the client's infectious process.

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.

Following thoracic surgery, what should the nurse include in the care plan for a client at risk for impaired gas exchange? Select all that apply.

Monitor vital signs frequently. Reinforce preoperative breathing exercises. Elevate head of bed 30 to 40 degrees as tolerated. Administer pain medications. Nursing management for a client with the goal of maintaining optimal gas exchange includes assessing vital signs frequently; reinforcing preoperative instructions about deep breathing, coughing, and incentive spirometry; and elevating the head of the bed as tolerated. Administering pain medications may help the client with breathing exercises. Accurate record of intravenous fluids is a nurse action, but not a client care issue.

A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first:

Oxygen therapy through a non-rebreather mask Explanation: The description is consistent with status asthmaticus. The client has not responded to treatment. Oxygen saturation is low. As oxygenation is the priority per Maslow's hierarchy of needs, oxygen therapy would be supplied first. Then, the nurse would initiate intravenous fluids and magnesium sulfate. Last, the nurse would encourage the client to drink fluids to prevent dehydration.

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 Explanation: 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.

The nurse is educating a patient with asthma about preventative measures to avoid having an asthma attack. What does the nurse inform the patient is a priority intervention to prevent an asthma attack?

Preparing a written action plan Explanation: 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 patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations (Expert Panel Report 3, 2007).

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.

A client presents to the ED experiencing symptoms of COPD exacerbation. The nurse understands that goals of therapy should be achieved to improve the client's condition. Which statements reflect therapy goals? Select all that apply.

Provide medical support for the current exacerbation. Treat the underlying cause of the event. Return the client to their original functioning abilities. Provide long-term support for medical management. Explanation: The goal is to have a stable client with COPD leading the most productive life possible. COPD cannot necessarily be cured, but it can be managed so that the client can live a reasonably normal life. With adequate management, clients should not have to give up their usual activities.

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.

The home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. For what potential complication should the home care nurse be most closely monitoring this client?

Residual effects of compromised oxygenation Explanation: The home care nurse should monitor the client for residual effects of the PE, which involved a severe disruption in respiration and oxygenation. PE has a noninfectious etiology; pneumonia is not impossible, but it is a less likely sequela. Swallowing ability is unlikely to be affected; activity level is important, but secondary to the effects of deoxygenation.

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 is developing a teaching plan for a client with COPD. What should the nurse include as the mostimportant area of teaching?

Setting and accepting realistic short- and long-term goals Explanation: A major area of teaching involves setting and accepting realistic short- and long-term goals. The other options should also be included in the teaching plan, but they are not areas that are as high a priority as setting and accepting realistic goals.

When developing a preventative plan of care for a patient at risk for developing chronic obstructive pulmonary disease (COPD), which of the following should be incorporated?

Smoking cessation Explanation: The most important risk factor for the development of COPD is cigarette smoking. The effects of cigarette smoke are complex and lead to the development of COPD in approximately 15% to 20% of smokers. Tobacco smoke irritates the airways and, in susceptible individuals, results in mucus hypersecretion and airway inflammation.

A client is being sent home with oxygen therapy. The nurse instructs that

Smoking or a flame is dangerous near oxygen. Explanation: The nurse should cautions the client against smoking or using a flame near oxygen. Oxygen is not addictive. Clients can travel with portable oxygen systems. Teaching also includes the proper flow of oxygen.

Which of the following is a clinical manifestation of a pneumothorax? Select all that apply.

Sudden chest pain Asymmetry of chest movement Unilateral retractions Oxygen desaturation Explanation: Signs and symptoms of pneumothorax include sudden chest pain that is sharp and abrupt, a significant and sudden increase in shortness of breath, asymmetry of chest movement, unilateral retractions, bilateral differences in breath sounds, and/or oxygen desaturation. The patient with a pneumothorax would not have bilaterally equal breath sounds.

A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing?

Take prescribed medications as scheduled. Explanation: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.

An older adult client has been diagnosed with COPD. What characteristic of the client's current health status would rule out the safe and effective use of a metered-dose inhaler (MDI)?

The client has severe arthritis in her hands. Explanation: Safe and effective MDI use requires the client to be able to manipulate the device independently, which may be difficult if the client has arthritis. Smoking does not preclude MDI use. A modest loss of vision does not preclude the use of an MDI and a client can safely use more than one MDI.

Why would a client with COPD report feeling fatigued? Select all that apply.

The client is using all expendable energy just to breathe. Lung function gradually decreases over time in clients with COPD. Explanation: The client is using all expendable energy just to breathe. Lung function, not muscle function, gradually decreases over time in clients with COPD. In a client with COPD, fatigue and a feeling of exhaustion stem directly from the disease, not from activity level.

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.

Which of the following are risk factors for the development of chronic obstructive pulmonary disease (COPD)? Select all that apply.

Tobacco smoke Occupational dust Air pollution Infection Second-hand smoke Explanation: Risk factors for chronic obstructive pulmonary disease are tobacco smoke, environmental tobacco smoke, occupational dust and chemicals, indoor and outdoor air pollution, and infection.

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because:

the airways are so swollen that no air can get through. Explanation: During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack.

A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply.

vaccinations hand antisepsis Explanation: A powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.