316- Chapter 55: Lower Respiratory Tract PREP U

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." Explanation: 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 nurse is teaching a client newly diagnosed with asthma about triggers. Which statement by the client indicates the teaching plan has been effective? "I will spray my bed and carpeting with dust mite killer." "I will use my air conditioner." "I will move my pet out of my bed and onto the bedroom floor." "I will wash my bedding monthly."

"I will use my air conditioner." Explanation: It is important that the client use the air conditioner if triggers are allergens, because of molds and pollens. Animals should not be in the bedroom. Bedding should be washed weekly. Aerosols may be a trigger.

When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instructions are needed when the client makes which of the following statements? "When I am short of breath, I will increase the use of my fluticasone." "I will wash my sheets weekly." "When I can do some, but not all of my usual activities, I am in the yellow zone." "I need to inhale my medication and hold my breath for 10 seconds."

"When I am short of breath, I will increase the use of my fluticasone." Explanation: Fluticasone is an inhaled steroid and should not be used during acute asthmatic attacks. Washing linens weekly will decrease the incidence of dust mites. When clients can participate in some, but not all of usual activities, they are in the yellow zone. Once medication is inhaled, the client should hold his or her breath for 10 seconds so that medication can reach deep into the lungs.

A patient with acute respiratory symptoms is receiving a loading dose of theophylline. Which of the following signs of toxicity should alert the nurse to notify the primary health care provider immediately?

- Abdominal cramps Explanation: It is important for the nurse to closely monitor the patient for signs of theophylline toxicity. The nurse should notify the primary health care provider immediately if any of the following signs of theophylline toxicity develop: anorexia, nausea, vomiting, diarrhea, confusion, abdominal cramping, headache, restlessness, insomnia, tachycardia, arrhythmias, or seizures. Constipation, bradycardia, or mental depression are not signs of theophylline toxicity.

When describing the action of xanthines, which would the nurse include? (Select all that apply.)

- Direct effect on the mobilization of calcium within the cell - Stimulation of 2 prostaglandins leading to smooth muscle relaxation - Inhibition of release of slow-reacting substance of anaphylaxis Explanation: Although the exact action is unknown, it is thought that xanthines 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.

A patient with asthma is administered zileuton along with theophylline. For which drug interaction should the nurse monitor the patient?

- Increased serum theophylline Explanation: When administering zileuton along with theophylline, the nurse should monitor for increased serum theophylline. Serum zileuton levels and pulse rate are not increased when zileuton is administered along with theophylline. Increased prothrombin time is seen when warfarin, and not theophylline, is given along with zileuton.

What is used to treat acute air flow obstruction?

- Metaproterenol (Alupent) Explanation: 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.

A client with asthma should always carry a rescue inhaler or quick-relief medication with them at all times. Which of the following are considered quick-relief medications? Select all that apply:

- Metaproterenol (Alupent) -Albuterol (Proventil) Explanation: Short-acting beta agonists (SABAs) are used as rescue treatment for asthma. B and D are SABAs, A and E are long-acting beta agonists (LABAs). C is a cholinergic-blocking drug.

Isoproterenol is an anticholinergic agent.

-False Isoproterenol is a sympathomimetic agent.

A patient, diagnosed with asthma, has been prescribed tiotropium. What should the nurse know about tiotropium? (Mark all that apply.)

-It is an anticholinergic -You only need to take it once a day - It has a rapid onset of action and a long duration Explanation: Tiotropium is the first drug approved for once-daily maintenance treatment of bronchospasm associated with COPD. Patients who cannot tolerate the sympathetic effects of the sympathomimetics might respond to the anticholinergic drugs ipratropium (Atrovent) or tiotropium (Spiriva). Tiotropium has a rapid onset of action and a long duration, with a half-life of 5 to 6 days.

A client with asthma should always carry a rescue inhaler or quick-relief medication with them at all times. Which of the following are considered quick-relief medications? Select all that apply: Salmeterol (Serevent) Metaproterenol (Alupent) Tiotropium (Spiriva) Albuterol (Proventil) Formoterol (Foradil)

-Metaproterenol (Alupent) - Albuterol (Proventil) Explanation: Short-acting beta agonists (SABAs) are used as rescue treatment for asthma. B and D are SABAs, A and E are long-acting beta agonists (LABAs). C is a cholinergic-blocking drug.

Xanthine derivatives elicit their effect by which mechanism?

-Stimulation of the central nervous system Explanation: Stimulation of the central nervous system is the mechanism of action for xanthine derivatives. Stimulation of beta-adrenergic receptors is the mechanism of action for beta-2 agonists. Reduction of airway hyper-responsiveness is the mechanism of action for inhaled corticosteroids. Stabilization of mast cell membranes is the mechanism of action for mast cell stabilizers.

A male patient is to begin treatment for pneumonia with an albuterol (Ventolin) inhaler. The nurse will advise the patient that he will most likely experience which common adverse effects of the drug?

-Throat irritation Explanation: The most common adverse effects of inhaled albuterol include throat irritation, palpitations, sinus tachycardia, anxiety tremor, and increased blood pressure. Serious adverse effects such as bronchospasm, urticaria, and angioedema rarely occur. Headache, dyspepsia, and muscle cramps are frequent adverse effects of oral albuterol only.

A patient is receiving aminophylline orally. The nurse would expect this drug to begin acting within which time frame?

1 to 6 hours Explanation: Aminophylline has an onset of action of 1 to 6 hours.

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 Explanation: The client should use the inhaler approximately 15 minutes before exercising to achieve the maximum therapeutic effects.

A female client is prescribed systemic corticosteroids for her asthma. The nurse knows that the client is at risk for what problem?

Adrenal insufficiency Explanation: Adrenal insufficiency is most likely to occur with systemic or high doses of inhaled corticosteroids.

A child is prescribed an inhaled corticosteroid agent to decrease respiratory inflammation related to exposure to an animal. The patient's parent administers high doses of the therapy after 2 days of administration. What is the patient at risk for?

Adrenal insufficiency Explanation: Adrenal insufficiency is most likely to occur with systemic or high doses of inhaled corticosteroids. The patient is not at risk for tachycardia, edema, or hypoglycemia unless related to adrenal insufficiency.

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.)

Affect metabolism of theophylline Decrease therapeutic effects Increase adverse effects Explanation: 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 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 Explanation: Inflammation and damaged airway mucosa are chronically present in asthma, even when clients appear symptom free.

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 Explanation: 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.

Which is an example of a short-acting beta-2 agonist (SABA)?

Albuterol Explanation: Albuterol is a SABA. Formoterol, salmeterol, and arformoterol are long acting beta-2 agonists (LABA).

The parents of a 7-year-old boy who has just been diagnosed with allergic asthma are being taught about their son's medication regimen by the nurse. The nurse is currently teaching the parent's about the appropriate use of a "rescue drug" for acute exacerbations of their son's asthma. What drug should the nurse suggests the parents to use in these situations?

Albuterol Explanation: Albuterol is a rescue drug that should be used first for all acute symptoms of shortness of breath or wheezing. Theophylline does not produce rapid symptom relief and beclomethasone is a maintenance drug. Acetylcysteine is not used in the treatment of asthma because it is used to manage secretions, which are not associated with asthma.

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 Explanation: 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. Explanation: 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.

One method of reducing bronchoconstriction is removing excessive secretions from the respiratory tract. Patients can take several actions on their own to help manage secretions. Which will not help manage secretions?

Asking the physician to prescribe inhaled corticosteroids Explanation: Although inhaled corticosteroids may be prescribed in the treatment of respiratory disorders, they act by reducing inflammation, not by removing secretions from the airway. The patient can thin secretions and make them easier to remove by consuming adequate amounts of fluids each day. The patient can also take mechanical measures, such as practicing deep breathing and coughing, to remove secretions.

A patient is experiencing an acute asthma attack. What is the first-line therapy for relief of an acute asthma attack?

Beta2-adrenergic agonist Explanation: A patient experiencing an acute asthma attack should be administered a beta2-adrenergic agonist. The patient can receive an inhaled steroid, but it is not the first-line therapy. Leukotriene modifiers are used for maintenance in asthma, not during acute exacerbation. Xanthines are not the drug of choice in acute asthma attack. Reference:

What does stimulation of alpha-adrenergic receptors result in?

Bronchoconstriction Explanation: Stimulation of alpha-adrenergic receptors results in bronchoconstriction.

Which would the nurse include as possible adverse effects when teaching a patient about albuterol? (Select all that apply.)

Bronchospasm Nervousness Sweating Explanation: Adverse effects associated with albuterol, a sympathomimetic, include CNS stimulation, GI upset, cardiac arrhythmias, hypertension, bronchospasm, sweating, pallor, and flushing.

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

Check blood pressure. Check pulse. Check respiratory rate Explanation: 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? Hyperthyroidism Cigarette smoking Gastrointestinal upset Alcohol intake

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 effects 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.

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 Alcohol Salt Vitamin C

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.

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

Decreased eosinophil migration Explanation: 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.

Which of the following would be most important to assess before administering calfactant? (Select all that apply.)

Endotracheal tube placement Lung sounds Oxygen saturation levels Explanation: Before administering calfactant, it would be important to ensure proper endotracheal tube placement because the drug is instilled directly into the trachea. In addition, lung sounds and oxygen saturation levels would be important as a baseline to evaluate effectiveness of the drug.

After teaching a group of students about antiasthmatic agents, the students demonstrate understanding of the information when they identify what as sympathomimetics? (Select all that apply.)

Epinephrine Terbutaline Formoterol Explanation: Epinephrine is a sympathomimetic. Terbutaline is a sympathomimetic. Formoterol is a sympathomimetic. Budesonide is an inhaled steroid. Tiotropium is an anticholinergic. Cromolyn is a mast cell stabilizer.

After teaching a group of students about leukotriene receptor antagonists, the instructor determines a need for additional teaching when the students identify which agent as an example?

Fluticasone Explanation: Fluticasone is an inhaled steroid. Montelukast is a leukotriene receptor antagonist. Zileuton is a leukotriene receptor antagonist. Zafirkulast is a leukotriene receptor antagonist.

The triage nurse in the emergency department has a 42-year-old patient with asthma present for treatment. The patient's respiratory rate is 40 breaths per minute. Based on this objective data, what is the correct nursing diagnosis for this patient? Activity intolerance Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern

Ineffective breathing pattern Explanation: The correct nursing diagnosis is Ineffective Breathing Pattern related to impaired airway as manifested by tachypnea. The other options may be applicable, but they do not take priority over the ineffective breathing pattern.

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

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

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

Inhalation Explanation: Salmeterol is administered via inhalation.

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. Explanation: 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. Explanation: 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.

A client with exercise-induced bronchospasm calls the physician's office to obtain a refill for his breathing medication. Which of the following should the nurse ask the physician to refill? Select all that apply:

Levalbuterol (Xopenex) Bitolterol (Tornalate) Explanation: Beta 2 agonists are used to treat exercise-induced bronchospam. B and E are beta 2 agonists. A and D are inhaled corticosteroids. C is a xanthine derivative.

A male client is prescribed montelukast and uses it successfully to manage his asthma. He develops hepatitis C. What would the nurse expect the physician to do? Lower the dose of the montelukast Discontinue the medication and prescribe another Increase the dose of the montelukast Maintain the same dose of the montelukast

Maintain the same dose of the montelukast Explanation: Montelukast and zafirlukast produce higher blood levels and are eliminated more slowly in clients with hepatic impairment. However, no dosage adjustment is recommended for clients with mild to moderate hepatic impairment.

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. Explanation: 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.

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

Myalgia Dizziness Vomiting Explanation: 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.

The client uses his sympathomimetic inhaler frequently. The nurse evaluates the client for which of the following symptoms related to frequent use of the sympathomimetic inhaler?

Nervousness Explanation: Frequent use of sympathomimetic inhalers can cause nervousness, hypertension, tachycardia, and anxiety.

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.

A female client presents to the emergency department with acutely deteriorating asthma. Her husband shows the nurse salmeterol when the nurse asks what medications his wife takes at home. He then tells the nurse that he gave her three extra puffs when she became ill. What statement is correct in this situation?

Salmeterol is contraindicated based on his wife's condition. Explanation: The FDA has issued a black box warning that initiating salmeterol in people with significantly worsening or acutely deteriorating asthma may be life threatening.

The client is 73 years of age and has a history of coronary artery disease and COPD. She is being started on formoterol (Foradil). The nurse would assess the client for which of the following conditions? Select all that apply.

Tachycardia Hypertension Explanation: Older adults taking adrenergic bronchodilators are at increased risk for adverse reactions related to the cardiovascular system, such as tachycardia (not bradycardia), arrhythmias, palpitations, and hypertension (not hypotension). Lethargy is not related to taking adrenergic bronchodilators.

A patient with bronchial asthma is prescribed a sustained-release preparation of theophylline. To help minimize the adverse effects of the drug, which of the following should the nurse suggest?

Take it on an empty stomach, 1 hour before or 2 hours after meals Explanation: Sustained-release preparations of theophylline should be taken on an empty stomach, 1 hour before or 2 hours after meals. Immediate-release preparations should be administered with meals to alleviate gastrointestinal distress. Foods containing xanthines, in particular caffeine, increase the effects of theophylline, but they do not help minimize the adverse effects of theophylline. Patients who smoke may require an increase in theophylline dosage of up to 50%, but increasing the dosage is not a nursing responsibility.

After teaching a group of students about inhaled steroids, the instructor determines that the teaching was successful when the students state:

The drugs are not for use during an acute attack. Explanation: The drugs are not for emergency use or use during an acute attack because their onset of action is slow. Systemic absorption is not typical with inhalation unless the patient did not administer the drug properly or has lesions that allowed absorption of the drug. Inhalation decreases the effectiveness of the inflammatory cells leading to decreased swelling and promotion of beta adrenergic receptor activity. The drugs are rapidly absorbed, but take 2 to 3 weeks to reach effective levels.

Leukotriene receptor antagonists are administered orally.

True

Cromolyn should not be used during an acute asthmatic attack.

True Explanation: Cromolyn is the only mast cell stabilizer still available and is available only in an OTC form. It is no longer considered part of the treatment standards because of the availability of more specific and safer drugs.

When educating a group of students on the mechanism of action of various anti-asthma drugs, the nurse identifies which drug as inhibiting the formation of leukotriene?

Zileuton Explanation: Zileuton acts by inhibiting the formation of leukotriene. Montelukast and zafirlukast act as leukotriene receptor antagonists. Budesonide is a corticosteroid drug that decreases the inflammatory process and increases the sensitivity of the B2 receptors.

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 effects with albuterol. The nurse should assess the patient's intake of caffeine through coffee, 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.

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. Explanation: 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.

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

soy and peanuts