Lower Respiratory PREPU

You have just finished teaching your 15-year-old patient how to use his inhaler to treat his asthma. What statement, made by your patient, suggests that he understands what you've taught him?

"I need to shake the inhaler well before taking the medication." Rationale: Just before each use, the patient 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.

Which statement by a client who is prescribed triamcinolone indicates the need for additional teaching?

"I should see some results in about 3 to 4 days." Rationale: Inhaled steroids, such as triamcinolone, can take from 2 to 3 weeks to reach effective levels, so the client should be encouraged to take them to reach and then maintain the effective levels. The drug is not effective for acute attacks. It can cause hoarseness and sore throat. The client should rinse his mouth after using the inhaler to decrease the risk of systemic absorption and decrease gastrointestinal upset and nausea.

The client has been prescribed cromolyn (Intal) for the treatment of asthma, and the nurse is evaluating the client's understanding of the medication. Which of the following statements by the client indicate the need for further education?

"I will use this medication when I am having an asthma attack." Rationale: Cromolyn (Intal) is a mast cell stabilizer used in combination with other drugs in the treatment of asthma and other allergic disorders. Adverse reactions include drying of the throat and coughing or wheezing. It should not be used during an acute asthma attack because it may worsen the bronchospasm.

The nurse assesses the serum theophylline of a patient. Which finding would the nurse identify as being therapeutic?

15 mcg/mL Rationale: Therapeutic theophylline levels range from 10 to 20 mcg/mL. A value of 15 mcg/mL would be considered therapeutic.

A client is using an inhaled bronchodilator as treatment for exercise-induced asthma. The nurse would instruct the client to use the inhaler at which time?

15 minutes before engaging in exercise Rationale: The client should use the inhaler approximately 15 minutes before exercising to achieve the maximum therapeutic effects.

A client who is experiencing anaphylaxis with severe wheezing receives a dose of epinephrine intravenously. The nurse would expect the drug to exert it full effects within which time frame?

20 minutes Rationale: When given intravenously, epinephrine peaks in approximately 20 minutes. It would be at this time that the drug is most effective.

A 5-year-old boy is brought to the ED with an asthma exacerbation, including wheezing (a high-pitched, whistling sound caused by turbulent airflow through an obstructed airway). Those who have asthma chronically present with what signs, even when they may appear symptom free? Select all that apply.

Airway inflammation Damaged airway mucosa Rationale: Inflammation and damaged airway mucosa are chronically present in asthma, even when clients appear symptom free.

Which of the following is an example of a short acting Beta 2 Agonist (SABA)?

Albuterol

A male client presents with symptoms of bronchospasm that occurred during a birthday party for his grandson. What medication would the nurse expect the physician to give him?

Albuterol Rationale: A selective, short-acting, inhaled beta2-adrenergic agonist (e.g., albuterol) is the initial rescue drug of choice for acute bronchospasm; subcutaneous epinephrine may also be considered.

During the summer, a female client experiences increased periods of acute symptoms of her asthma. The physician increases the dose frequency of which of her medications?

Albuterol Rationale: Albuterol is the initial drug of choice for acute bronchospasm.

Mr. Ashum is prescribed an albuterol inhaler as part of his treatment regimen for asthma. What is the mechanism of action for this medication?

Albuterol causes relaxation of the bronchial smooth muscles. Rationale: The main result of albuterol binding to beta-2 receptors in the lungs is relaxation of bronchial smooth muscles. This relaxation of bronchial smooth muscle relieves bronchospasm, reduces airway resistance, facilitates mucous drainage, and increases vital capacity.

The asthmatic client is being treated with two inhalers, albuterol and flunisolide. The nurse teaches the client that the two medications should be administered in what order?

Albuterol first, wait five minutes and then follow with flunisolide Rationale: Albuterol is a bronchodilator and should be used first, given time to open the airways, and then the inhaled corticosteroid is administered.

Which of the following would a nurse identify as a surfactant?

Beractant Rationale: Beractant is a lung surfactant. Cromolyn is a mast cell stabilizer. Zileuton is a leukotriene receptor antagonist. Theophylline is a xanthine.

Your patient, an elderly woman, insists her asthma is exacerbated by her least favorite television show. While explaining that her dislike for the show's host may be a contributing factor, you explain that an asthma attack is caused by substances released from mast cells, which cause:

Bronchoconstriction and inflammation. Rationale: When lung tissues are exposed to causative stimuli, mast cells release substances that cause bronchoconstriction and inflammation.

The nurse should complete which of the following during acute breathing distress before initiation of a broncodilator? Select all that apply:

Check pulse. Check blood pressure. Check respiratory rate Rationale: Prior to initiation of a bronchodilator during acute breathing distress, the nurse needs to take a blood pressure, pulse, and respiratory rate.

A nurse would expect to increase the dosage of theophylline if the client has a current history of which of the following?

Cigarette smoking Rationale: 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 effects of the drug. The drug dosage may need to be decreased in these situations.

The client's theophylline levels are increased. The nurse questions the client about his intake of which of the following?

Coffee Rationale: Xanthines are found in colas, coffee, chocolate, and charcoal-prepared foods. This could cause the client's theophylline levels to increase. Neither tea, carrots, nor cheese affect theophylline levels.

The nurse is caring for a client who is receiving IV theophylline for treatment of severe bronchospasm. The nurse will ensure that which item on the client's food tray will be held while the client is receiving theophylline?

Coffee Rationale: Theophylline is a xanthine, which has properties that are close to caffeine; therefore, the nurse will ensure that the client doesn't have anything on the tray that has caffeine in it.

A patient is experiencing an acute asthma attack. Which of the following medications are contraindicated for the treatment of acute asthma?

Cromolyn (Intal) Rationale: Cromolyn stabilizes mast cells and is not used in acute bronchospasm. Aminophylline is used in limited cases, but is administered for acute asthma attack. Albuterol is used for acute asthma attack. Corticosteroids are administered for acute asthma attack to decrease inflammation.

Which of the following effects would result from the action of montelukast?

Decreased eosinophil migration Rationale: Montelukast selectively and competitively blocks receptors for the production of leukotrienes D4 and E4, which are components of slow-reacting substance of anaphylaxis. As a result, the drug blocks many of the signs and symptoms of asthma, such as neutrophil and eosinophil migration, neutrophil and monocyte aggregation, leukocyte adhesion, increased capillary permeability, and smooth muscle contraction.

The client has mild, persistent asthma. The nurse anticipates the health care provider prescribing which of the following daily medications?

Fluticasone Rationale: Terbutaline, albuterol, and levalbuterol are all short-acting beta-2 agonists that are used for acute symptom relief. Fluticasone is a daily inhaled corticosteroid.

With theophylline, the home care nurse needs to assess the client and the environment for certain products that can cause what to occur? (Select all that apply.)

Increase adverse effects Decrease therapeutic effects Affect metabolism of theophylline Rationale: With theophylline, the home care nurse needs to assess the client and the environment for substances that may affect metabolism of theophylline and decrease therapeutic effects or increase adverse effects. Issues with excretion of theophylline are rarely an issue.

A patient is prescribed salmeterol. The nurse would expect this drug to be administered by which route?

Inhalation Rationale: Salmeterol is administered via inhalation.

A nurse is administering levalbuterol to a client. The nurse would administer this drug by which route?

Inhalation Rationale: Levalbuterol is administered only as an inhalant by nebulizer.

A patient is instructed on the administration of inhaled corticosteroid agents to treat asthma. How do inhaled corticosteroid agents assist in the treatment of asthma?

Inhaled corticosteroid agents will reduce airway inflammation. Rationale: Inhaled corticosteroid agents suppress the release of inflammatory mediators, block the generations of cytokines, and decrease the recruitment of airway eosinophils. Inhaled corticosteroid agents do not depress the central nervous system. Inhaled corticosteroid agents do not affect bronchodilation or constriction.

Mark, 8 years old, is prescribed flunisolide. The physician advises Mark and his parents to use a spacer when administering this medication. What is the benefit of such use?

It helps decrease systemic absorption. Rationale: Spacers help decrease systemic absorption, because less flunisolide is swallowed. Spacers may also help alleviate dysphonia by filtering larger aerosol particles that ordinarily deposit in the oropharynx and extrathoracic airways (this precaution also reduces the risk for oropharyngeal candidiasis). The use of a spacer does not prevent intrapulmonary delivery of the drug; nor does it reduce the risk of tachycardia and sinusitis.

Which agents would the nurse identify as selectively and competitively blocking the receptors for the production of two substances that are components of SRSA?

Leukotriene receptor antagonists Rationale: Leukotriene receptor antagonists selectively and competitively block or antagonize receptors for the production of leukotrienes D4 and E4, components of SRSA. Xanthines are thought to work by directly affecting the mobilization of calcium within the cell by stimulating two prostaglandins, resulting in smooth muscle relaxation. Xanthines also inhibit the release of slow-reacting substance of anaphylaxis (SRSA) and histamine. Mast cell stabilizers work at the cellular level to inhibit the release of histamine (released from mast cells in response to inflammation or irritation) and inhibits the release of SRSA. Anticholinergics are used as bronchodilators because of their effect on the vagus nerve, which is to block or antagonize the action of the neurotransmitter acetylcholine at vagal-mediated receptor sites.

Which of the following is used to treat acute air flow obstruction?

Metaproterenol (Alupent) Rationale: Metaproterenol (Alupent) is a short acting Beta 2 agonist used as a quick relief medication. Qvar is an inhaled corticosteroid used as a long-term control medication. Singulair is a leukotriene antagonist used for prophylactic treatment of chronic asthma. Astelin is a second-generation antihistamine.

An 8-year-old child with an acute asthmatic attack is receiving metaproterenol via nebulizer. Which of the following would be most appropriate?

Mix the drug with saline. Rationale: Metaproterenol is mixed with saline in the nebulizer chamber for administration. The child should sit upright or be in a semi-Fowler's position. He should breathe slowly and deeply during the treatment. The treatment is completed when all of the solution (liquid) is gone from the chamber.

A client with COPD takes theophylline. The nurse identifies that the client is still experiencing severe dyspnea. Upon review of labs, the theophylline level remains nontherapeutic. The nurse evaluates the client for which of the following drugs that may cause decreased theophylline levels?

Nicotine Rationale: When combined with nicotine, theophylline levels are decreased. Allopurinol, cimetidine, and corticosteroids can increase theophylline levels.

While reviewing a client's history, an allergy to which of the following would alert the nurse to a possible problem with the use of ipratropium?

Peanuts Rationale: The use of ipratropium is contraindicated in the presence of known allergy to the drug or to peanuts or soy products because the vehicle used to make ipratropium, an aerosol, contains a protein associated with peanut allergies.

The nurse is teaching a client how to prevent Candida infections. Which of the following would the nurse include in the instructions?

Rinse mouth with water after each use. Rationale: The client should be taught to rinse his mouth out with water after using oral inhalers to prevent a Candida oral infection.

When describing the action of mast cell stabilizers, which of the following would the nurse include as being inhibited?

Slow-reacting substance of anaphylaxis Rationale: Mast cell stabilizers work at the cellular level to inhibit the release of histamine and the release of slow-reacting substance of anaphylaxis. Epinephrine is not affected by mast cell stabilizers. Xanthines are thought to work by directly affecting the mobilization of calcium within the cell by stimulating two prostaglandins.

A history of an allergy to which of the following would be a contraindication to the use of anticholinergics? Select all that apply.

Soy Peanuts Rationale: The use of ipratropium and tiotropium, anticholinergics, is contraindicated in the presence of known allergy to soy products or peanuts.

A patient is started on albuterol (Proventil). What reaction should the patient be instructed on?

Tachycardia will occur. Rationale: The symptoms of cardiac stimulation, including tachycardia, are noted with the administration of albuterol. The patient will not experience polydipsia, hypotension, or diarrhea.

A man who smokes one pack of cigarettes daily has been diagnosed with chronic bronchitis. He has been prescribed theophylline by his family doctor. What effect will the patient's smoking status have on the therapeutic use of theophylline?

The patient may require higher doses of theophylline than a nonsmoker Rationale: Smoking cigarettes may decrease serum theophylline levels. In fact, some patients who smoke require an increase in theophylline dosage of up to 50%. Theophylline is not associated with a risk of anaphylactoid reaction. Theophylline doses do not need to be concurrent with the use of bronchodilators.

Aerosols are often the drugs of choice to treat asthma because of what characteristics? (Select all that apply.)

They act directly on the airways. They can usually be given in smaller doses. They produce fewer adverse effects than oral or parenteral drugs. They relieve symptoms quickly. Rationale: Because aerosol products act directly on the airways, drugs given by inhalation can usually be given in smaller doses and produce fewer adverse effects than oral or parenteral drugs. Aerosol products also produce a relief of asthma symptoms in a quick fashion.

Cromolyn should not be used during an acute asthmatic attack.

True

Leukotriene receptor antagonists are administered orally.

True

A patient is being assessed by the home care nurse on the administration of the inhalers. Which of the following will assist in proper administration of the inhaler?

Use of a spacer Rationale: The patient should be instructed to use a spacer to increase compliance and accuracy of administration. The corticosteroid should be administered after the bronchodilator. The increase in fluids will not affect the administration of the inhaler. The patient should hold his breath for several seconds after administration of the inhaler.

After teaching a group of students about zafirlukast, the students demonstrate understanding when they identify which of the following as possible adverse effects? Select all that apply.

Vomiting Myalgia Dizziness Rationale: Myalgia is a possible adverse effect of zafirkulast. Dizziness is a possible adverse effect of zafirkulast. Vomiting is a possible adverse effect of zafirkulast. Constipation is not associated with zafirlukast. Chills are not associated with zafirkulast.

A high school student was diagnosed with asthma when he was in elementary school and has become accustomed to carrying and using his "puffers". In recent months, he has become more involved in sports and has developed a habit of administering albuterol up to 10 times daily. The nurse should teach the student that overuse of albuterol can lead to

rebound bronchoconstriction. Rationale: Patients who self-administer albuterol may use their MDIs more frequently than recommended. This practice can result in rebound bronchoconstriction, which may motivate the patient to increase MDI use, stimulating the cycle of rebound congestion. Overuse of albuterol is not linked to pneumonia or hepatotoxicity. Albuterol is not an anticholinergic drug.