The 3-1: Obstructive Pulmonary Diseases

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced assistive personnel (AP)? a. Measure O2 saturation using pulse oximetry. b. Monitor for increased O2 need with exercise. c. Teach the patient about safe use of O2 at home. d. Adjust O2 to keep saturation in prescribed parameters.

ANS: A AP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions require more education and a scope of practice that licensed practical/vocational nurses (LPN/VNs) or registered nurses (RNs) would have.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment would the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Measure forced expiratory volume (FEV) flow rate.

ANS: A Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Report of sharp chest pain with deep breathing c. Scattered crackles and wheezes heard bilaterally d. Respiratory rate 28 breaths/min while ambulating

ANS: A Hemoptysis may indicate life-threatening hemorrhage and would be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications.

Which action by the nurse would support ventilation for a patient with chronic obstructive pulmonary disease (COPD).? a. Encourage the patient to sit upright and lean forward. b. Have the patient rest with the head elevated 15 degrees. c. Place the patient in the Trendelenburg position with pillows behind the head. d. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed.

ANS: A Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.

The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. O2 saturation is >90%. b. No wheezes are audible. c. Respiratory rate is 16 breaths/min. d. Accessory muscle use has decreased.

ANS: A The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. Absence of wheezes, slower respiratory rate, and decreased accessory muscle use may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.

The nurse in the emergency department receives arterial blood gas results for 4 recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

ANS: A The low pH, high PaCO2, and low PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action would the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

ANS: A The patient's assessment indicates impending respiratory failure, and the nurse would prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction would the nurse include in the discharge teaching? a. O2 use can improve the patient's quality of life. b. Travel is not possible with the use of O2 devices. c. O2 flow should be increased if the patient has more dyspnea. d. Storage of O2 requires large metal tanks that last 4 to 6 hours.

ANS: A The use of home O2 improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the health care provider rather than increasing the O2 flowrate if dyspnea becomes worse. O2 can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable O2 concentrators.

A 30-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which topic would the nurse plan to teach the patient? a. α1-Antitrypsin testing b. Leukotriene modifiers c. Use of the nicotine patch d. Continuous pulse oximetry

ANS: A When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in α1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD.

2. The home health nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient lies in supine position when using the nebulizer. b. The patient removes the facial mask when the misting stops. c. The patient reports washing the nebulizer mouthpiece weekly. d. The patient inhales while holding the mask 4 inches away from the face.

ANS: B A mist is seen when the medication is aerosolized, and when all the medication has been used, the misting stops. The mask should be placed securely on the patient's face or the mouthpiece held between the teeth with the lips closed around the device. The patient should be positioned sitting upright. The home nebulize equipment should be washed and dried daily.

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema

ANS: B A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea.

The nurse teaches a patient who has chronic bronchitis about a new prescription for combined fluticasone and salmeterol (Advair Diskus) in a dry powder inhaler. Which patient action indicates to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient rapidly inhales the medication. c. The patient attaches a spacer to the device. d. The patient performs huff coughing after inhalation.

ANS: B Advair Diskus is a dry powder inhaler; the patient should inhale the medication rapidly, or the dry particles will stick to the tongue and oral mucosa. Shaking dry powder inhalers is not recommended. Spacers are not used with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient should not huff cough or exhale forcefully after taking Advair to keep the medication in the lungs.

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication would the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)

ANS: B Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.

Which inhaler would the nurse be prepared to administer to the patient at the onset of an asthma attack? a. Albuterol b. Fluticasone c. Salmeterol d. Tiotropium

ANS: B All guidelines recommend using inhaled corticosteroids (ICS) as first-line agents in an acute asthma attack and as the first step in acute asthma management. Fluticasone is an ICS. Albuterol is a short-acting bronchodilator (SABA). While inhaled SABAs remain effective drugs for relieving acute bronchospasm (as seen in an acute asthma attack), they are no longer first-line therapy. Salmeterol is a long-acting bronchodilator (LABA) and like SABAs, LABAs should not to be used alone as primary treatment. They should be used only if the patient does not respond to medium-dose ICS. Tiotropium is a long-acting anticholinergic bronchodilator that is recommended only for use in chronic obstructive pulmonary disease. (pg 644-646)

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a. Pain at injection site b. Flushing and dizziness c. Respiratory rate 24 breaths/min d. Peak flow reading 75% of normal

ANS: B Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate intervention is needed. The other information would also be reported, but do not indicate possibly life-threatening complications of omalizumab therapy.

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? a. "I will drink lots of fluids with my meals." b. "I can have ice cream as a snack every day." c. "I will exercise for 15 minutes before meals." d. "I will decrease my intake of beef and poultry."

ANS: B High-calorie foods such as ice cream are an appropriate snack for underweight patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which action would the nurse implement for a patient who has an impaired breathing pattern due to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use the pursed-lip technique. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.

ANS: B Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

Which assessment finding is most useful in evaluating the effectiveness of treatment to improve gas exchange? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min

ANS: B The best data for evaluation of gas exchange are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How would the nurse determine the appropriate O2 flowrate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.

ANS: B The best way to determine the appropriate O2 flowrate is by monitoring the patient's oxygenation either by arterial blood gases (ABGs) or pulse oximetry. An O2 saturation of 90% indicates adequate blood O2 level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an O2 flowrate of 2 L/min may not be adequate. Because O2 use improves survival rate in patients with COPD, there is no concern about O2 dependency. The patient's perceived dyspnea level may be affected by other factors (e.g., anxiety) besides blood O2 level.

When preparing a clinic patient who has chronic obstructive pulmonary disease (COPD) for pulmonary spirometry, which question would the nurse ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"

ANS: C Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present because they are contraindications for an MRI.

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action would the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Teach the patient to use the prescribed albuterol (Ventolin HFA). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.

ANS: B The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting β2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is appropriate but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed at this point.

A patient seen in the asthma clinic has recorded daily peak flowrates that are 70% of the baseline. Which action will the nurse plan to take next? a. Teach the patient about the use of oral corticosteroids. b. Administer a bronchodilator and recheck the spirometry. c. Recommend increasing the dose of the leukotriene inhibitor. d. Instruct the patient to keep the scheduled follow-up appointment.

ANS: B The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient would take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient first needs to be taught how to control symptoms now and use the bronchodilator.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which patient problem would the nurse identify? a. Fear of death b. Low self-esteem c. Anticipatory grieving d. Lack of knowledge

ANS: B The patient's statement about not being able to do anything for himself or herself reflects low selfesteem. Although lack of knowledge, anticipatory grieving, and fear of death may be problems for some patients who have COPD, the data for this patient do not support these problems.

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is specific in confirming a diagnosis of chronic bronchitis? a. The patient relates a family history of bronchitis. b. The patient has a 30 pack-year cigarette smoking history. c. The patient reports a productive cough for 3 months of every winter. d. The patient has respiratory problems that began during the past 12 months.

ANS: C A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no family tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.

Which action would the nurse take to prepare a patient for spirometry? a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test.

ANS: C Bronchodilators are held before spirometry so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should be held before spirometry. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

Which finding would the nurse expect when assessing a patient with cor pulmonale? a. Chest pain b. Finger clubbing c. Peripheral edema d. Elevated temperature

ANS: C Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not indicators of cor pulmonale.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care? a. Walk until pulse rate exceeds 130 beats/min. b. Stop exercising when you feel short of breath. c. Walk 15 to 20 minutes a day at least 3 times/wk. d. Limit exercise to activities of daily living (ADLs).

ANS: C Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise (80% of the maximal heart rate of 150 beats/min).

A patient with chronic obstructive pulmonary disease (COPD) has been eating very little and has lost weight. Which intervention would be most important for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's menu order of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.

ANS: C Underweight patients need extra protein and calories; eating small amounts more often (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Whole grains, fruits, and vegetables are part of a well-balanced diet, but the patient with COPD who is underweight needs an emphasis on protein to maintain muscle tissue needed for breathing.

Which instruction would the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercises to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while exercising."

ANS: C Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.

Which assessment finding for a patient with a history of asthma indicates that the nurse would take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min

ANS: C Use of accessory muscle indicates that the patient with asthma is experiencing respiratory distress, and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

ANS: C β-Blockers such as propranolol inhibit bronchodilation. The other information will be documented in the health history but does not indicate a need for a change in therapy.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which of the following interventions is best to address this problem? a. Increase the client's intake of fruits and fruit juices. b. Have the client exercise for 10 minutes before meals. c. Assist the client in choosing foods with a lot of texture. d. Offer high calorie snacks between meals and at bedtime.

ANS: D Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Clients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.

A patient newly diagnosed with asthma is being discharged. Which topic would the nurse include in the discharge teaching? a. Complications associated with O2 therapy b. Use of long-acting β-adrenergic medications c. Side effects of sustained-release theophylline d. Self-administration of inhaled corticosteroids

ANS: D Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.

The nurse completes an admission assessment on a patient with asthma. Which information indicates a need for discussion with the health care provider about a change in therapy? a. The patient uses an albuterol inhaler before aerobic exercise. b. The patient's only medications are albuterol and salmeterol inhalers. c. The patient's heart rate increases slightly after using the albuterol inhaler. d. The patient used albuterol more often when symptoms were worse in the spring.

ANS: D Long-acting β2-agonists would be used only in patients who also are using an inhaled corticosteroid for long-term control; salmeterol would not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention would the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.

ANS: D Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium.

Which of the following information should the nurse include when teaching the client with asthma about the prescribed medications? a. Utilize the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry-powder inhaler (DPI). c. Hold your breath for 2 seconds after using the bronchodilator inhaler. d. Tremors are an expected adverse effect of rapidly acting bronchodilators.

ANS: D Tremors are a common side effect of short-acting β2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.