302 Hinkle Chapter 24: Management of Patients with Chronic Pulmonary Disease PrepU

A nurse evaluates the results of a spirometry test to help confirm a diagnosis of obstructive lung disease. Which one of the following results indicates an initial early stage of COPD? (FEV1 refers to forced expired volume in 1 second.)

FEV1> 80% The FEV1 decreases as the severity of obstruction increases. Therefore, an FEV1 of more than 80% indicates an initial stage, and an FEV1 of 30% indicates a very severe stage.

A client is prescribed methylprednisolone (Solu-Medrol) 125 mg intravenously. The medication is available in a 125 mg single-dose vial containing 2 mL. The nurse will administer methylprednisolone over 2 minutes. How many mL will the nurse administer each 15 seconds? Write your answer to 2 decimal places. Starting with 0., enter the correct number ONLY.

0.25 The volume to be infused is 2 mL over 2 minutes. There are 60 seconds in each minute. For every 15 seconds, the nurse will administer 0.25 mL. 2 mL/120 sec = x/15 sec. 0.25 mL = x

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) 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 notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 85% for a patient with COPD. What stage should the nurse document the patient is in?

I All grades of COPD are associated with an FEV1/FVC ratio of less than 70%. Grade I (mild) is associated with an FEV1 of greater than or equal to 80%. Grade II (moderate) is associated with an FEV1 of 50%-80%. Grade III is associated with an FEV1 of <30%-50%. Grade IV is associated with an FEV1 of <30%.

Which of the following medications are classified as leukotriene modifiers (inhibitors)? Select all that apply.

Montelukast Zafirlukast Zileuton Montelukast (Singulair), Zafirlukast (Accolate), and Zileuton (Zyflo) are leukotriene modifiers. Ipratropium HFA (Atrovent) is a short-acting anticholinergic. Tiotropium (Spiriva) is a long-acting anticholinergic.

The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is:

Respiratory acidosis Decreased carbon dioxide elimination results in increased carbon dioxide tension (hypercapnia), which leads to respiratory acidosis and chronic respiratory failure.

A nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). What instructions should the nurse include in the teaching? Select all that apply.

Take a slow, deep inhalation from the device. Activate the MDI once. The device may increase delivery of the MDI medication The pictured device is a spacer, which is attached to an MDI for client use. The client activates the MDI once and takes a slow, deep inhalation, not normal inhalations. The client then holds the breath for 10 seconds. The spacer may increase delivery of the MDI medication.

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 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 home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met?

decreased oxygen requirements A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

The client is prescribed albuterol 2 puffs as a metered-dose inhaler. Which action by the client demonstrates understanding of administration for this medication?

position the inhaler two finger widths away from the lips 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.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?

teaching the client how to perform controlled coughing Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.

A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed?

with meals Nearly 90% of clients with cystic fibrosis have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals.

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 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.

Which of the following is a common irritant that acts as a trigger of asthma?

esophageal reflux Esophageal reflux, viral respiratory infections, cigarette smoke, and exercise are all irritants that can trigger asthma. Peanuts, aspirin sensitivity, and molds are antigens

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?

ineffective coping related to anxiety Any factor that interferes with normal breathing quite naturally induces anxiety, depression, and changes in behavior. Constant shortness of breath and fatigue may make the patient irritable and apprehensive to the point of panic. Although the other choices are correct, the most important psychosocial nursing diagnosis for a patient with COPD is ineffective coping related to a high level of anxiety.

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive?

influenza Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for women ages 9 to 26.

A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is:

sharp stabbing chest pain The initial symptom is usually chest pain of sudden onset that leads to feelings of chest pressure, dyspnea, and tachycardia. A cough may be present.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he:

uses the sternocleidomastoid muscles Use of accessory muscles indicates worsening breathing conditions. Assuming the tripod position, a 93% pulse oximetry reading, and a request for the nurse to raise the head of the bed don't indicate that the client's condition is worsening.

A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action?

if cough occurs during the procedure, repeat it Steps for using the peak flow meter correctly include (1) moving the indicator to the bottom of the numbered scale; (2) standing up; (3) taking a deep breath and filling the lungs completely; (4) placing the mouthpiece in the mouth and closing the lips around it; (5) blowing out hard and fast with a single blow; and (6) recording the number achieved on the indicator. If the client coughs or a mistake is made in the process, repeat the procedure. Peak flow readings should be taken during an asthma attack.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

respiratory acidosis As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

A client is being treated in the ED for respiratory distress coupled with 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 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 55-year-old client is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse

ask the client, "What are your allergies?" Spirometry testing includes use of a bronchodilator and then further testing. The nurse needs to assess for allergies first. The client does not need to be NPO prior to spirometry testing. Venous blood work may be done for clients younger than 45 years old, to check for a deficiency in alpha 1-antitrypsin. Arterial blood gases, if ordered, are obtained prior to spirometry testing.

A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer an ordered nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm finished, I'll come and assess the client." The nurse's most appropriate action is to:

give the nebulizer treatment herself The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the respiratory therapist's lack of response after the client's condition is stabilized. There is no need to involve the physician in personnel issues. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment not a metered-dose inhaler, so the nurse can't change the route without a new order from the physician.

A physician orders metaproterenol by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?

"I need to hold my breath as long as possible after I take a deep inhalation" The client demonstrates effective teaching if he states that he'll hold his breath for as long as possible after inhaling the drug. Holding the breath increases the absorption of the drug into the alveoli. Metaproterenol (Alupent) needs to be used over an extended period for maximum effect. The client shouldn't use the inhaler whenever he feels out of breath because dependency can develop if the drug is used excessively. The client should adhere to the prescribed dosage. Tachycardia is an expected adverse reaction to metaproterenol. The client should be taught how to monitor his heart rate and contact the physician only if the heart rate exceeds 130 beats/minute.

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 will make sure that my oxygen mask is on tightly so it won't slip off while I nap" 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.

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.

60 mm Hg; 90% The goal is a PaO2 of at least 60 mm Hg and an SaO2 of 90%.

The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient would the nurse assess first?

An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office On the patient's arrival at the emergency department, the first line of treatment is supplemental oxygen therapy and rapid assessment to determine if the exacerbation is life-threatening. Pulse oximetry is helpful in assessing response to therapy but does not assess PaCO2 levels. The fluids will not run out during the very beginning of the shift. The vital signs listed are normal findings for patients with COPD.

In which grade of COPD is the forced expiratory volume in 1 second (FEV1) greater than 80% predicted?

I COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate): FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC <70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70% and FEV1 <30% predicted.

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 40% for a patient with COPD. What stage should the nurse document the patient is in?

III All grades of COPD are associated with an FEV1/FVC ratio of less than 70%. Grade I (mild) is associated with an FEV1 of greater than or equal to 80%. Grade II (moderate) is associated with an FEV1 of 50%-80%. Grade III is associated with an FEV1 of <30%-50%. Grade IV is associated with an FEV1 of <30%.

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 25% for a patient with COPD. What stage should the nurse document the patient is in?

IV All grades of COPD are associated with an FEV1/FVC ratio of less than 70%. Grade I (mild) is associated with an FEV1 of greater than or equal to 80%. Grade II (moderate) is associated with an FEV1 of 50%-80%. Grade III is associated with an FEV1 of <30%-50%. Grade IV is associated with an FEV1 of <30%.

In which grade of COPD is the forced expiratory volume in 1 second (FEV1) less than 30% predicted?

IV COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate): FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC <70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70% and FEV1 <30% predicted.

Which of the following factors contribute to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Select all that apply.

Inflamed airways obstruct airflow. Mucus secretions block airways. Overinflated alveoli impair gas exchange Because of the chronic inflammation and the body's attempts to repair it, changes and narrowing occur in the airways. In the peripheral airways, inflammation causes thickening of the airway wall, peribronchial fibrosis, exudate in the airway, and overall airway narrowing (obstructive bronchiolitis). The airways are actually moist, not dry. In the proximal airways, changes include increased goblet cells and enlarged submucosal glands, both of which lead to hypersecretion of mucus.

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 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.

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 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 physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?

administer the salmeterol and then administer the triamcinolone A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone (Azmacort) is a corticosteroid; Salmeterol (Serevent) is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

What are the primary causes for an acute exacerbation of COPD? Select all that apply.

air pollution tracheobronchial infection Common causes of an acute exacerbation include tracheobronchial infection and air pollution. However, the cause of approximately one third of severe exacerbations cannot be identified. Change in season from spring to summer, hypertension, and GI viruses are not causes of exacerbation of COPD. Winter is worse for COPD when viral and bacterial infections are more prevalent.

During a teaching session, a parent asks the nurse which inhaler to use for quick relief if the child has an asthma attack. What teaching should the nurse review with the parent?

albuterol is a short acting inhalant and will relax muscles quickly Short-acting beta2-adrenergic agonists, such as albuterol (AccuNeb, Proventil, Ventolin), levalbuterol (Xopenex HFA), and pirbuterol (Maxair), are the inhalant medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade) are mild to moderate anti-inflammatory agents that stabilize mast cells, and are contraindicated in acute asthma exacerbations. Long-acting beta2-adrenergic agonists, such as theophylline (Slo-Bid, Theo- Dur) and salmeterol (Serevent Diskus), are not indicated for immediate relief of symptoms.

A client with asthma is being treated with albuterol. Which of the findings from the client's history would indicate to the nurse the need to administer this drug with caution?

angina Patients, especially older adults, with pre-existing cardiovascular disease may have adverse cardiovascular reactions with inhaled therapy. Albuterol (Proventil) does not increase the secretions of the GI tract or cause gastric irritation. It will not worsen a peptic ulcer.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

anxiety In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

A client arrives in the emergency room with emphysema and has developed an exacerbation of COPD with respiratory acidosis from airway obstruction. What is the highest priority for the nurse?

apply supplemental oxygen as ordered When the client arrives in an ED, the first line of treatment is supplemental oxygen therapy and rapid assessment. 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 the adequacy of oxygenation.

A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take?

assess fasting blood glucose levels Adverse effects of methylprednisolone (Solu-Medrol) include abnormalities in glucose metabolism. The nurse monitors blood glucose levels. Methylprednisolone also increases the client's appetite and fluid retention, but the client will not decrease caloric or fluid intake as a result of these adverse effects. It is not necessary to aspirate for blood return prior to injecting the medication, because doing so would not support the intravenous line in the vein.

Which of the following is the most common chronic disease of childhood?

asthma Asthma is the most common chronic disease of childhood but occurs for the first time at any age, including the elderly. Asthma may affect school and work attendance, occupational choices, physical activity, and general quality of life.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as

atelectasis Retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

beta 2 adrenergic agonist An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects. The I.V. form is typically used when the inhaled beta2-adrenergic agonist doesn't work. A corticosteroid is slow acting, so its use won't reduce hypoxia in the acute phase.

Which of the following is a leading cause of chronic obstructive pulmonary disease (COPD) exacerbation?

bronchitis A wide range of viral, bacterial, and mycoplasmal infections can produce acute episodes of bronchitis, a leading cause of exacerbations. Pneumonia, the common cold, and asthma are not leading causes of exacerbations.

Which of the following occupy space in the thorax, but do not contribute to ventilation?

bullae Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax. Bullae may compress areas of healthier lung and impair gas exchange. Alveoli are the functional units of the lungs. Lung parenchyma is lung tissue. Mast cells, when activated, release several chemicals called mediators that include histamine, bradykinin, prostaglandins, and leukotrienes.

Which drug is second-line pharmacotherapy for smoking abstinence?

clonidine Second-line pharmacotherapy includes the antihypertensive agent clonidine. However, its use is limited by its side effects. First-line therapy includes nicotine gum, nortriptyline, and bupropion SR.

A client has asthma. Which of the following medications is a commonly prescribed mast cell stabilizer used for asthma?

cromolyn sodium Cromolyn sodium and nedocromil are mild to moderate anti-inflammatory agents and are considered alternative medications for treatment. These medications stabilize mast cells. Though also used in the treatment of asthma the following are NOT mast cell stabilizers: Albuterol is a beta2-antagonist. Budesonide is an inhaled corticosteroid. Theophylline is a mild to moderate bronchodilator.

Which medication is contraindicated in acute asthma exacerbations?

cromolyn sodium Cromolyn sodium is contraindicated in clients with acute asthma exacerbation.

A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations?

cromolyn sodium Cromolyn sodium is contraindicated in clients with acute asthma exacerbation. Indications for cromolyn sodium are long-term prevention of symptoms in mild, persistent asthma; it may modify inflammation. Cromolyn sodium is also a preventive treatment before exposure to exercise or a known allergen. Albuterol, levalbuterol HFA, and ipratropium can be used to relieve acute symptoms.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue?

delay self-care activities for 1 hour Some clients with COPD have shortness of breath and fatigue in the morning on arising as a result of bronchial secretions. Planning self-care activities around this time may be better tolerated by the client, such as delaying activities until the client is less short of breath or fatigued. The client raising the arms over the head may increase dyspnea and fatigue. Sitting in a chair when bathing or dressing will aid in dyspnea and fatigue but does not address the situation upon arising. Drinking fluids will assist in liquifying secretions which, thus, will aid in breathing, but again does not address the situation in the morning.

A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take?

encourage the client to exhale slowly against purses lips When a client with COPD exhibits shallow, rapid, and inefficient respirations, the nurse encourages the client to perform pursed-lip breathing, which includes exhaling slowly against pursed lips. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps the client control the rate and depth of respiration. It also promotes relaxation, enabling the client to gain control of dyspnea and reduce feelings of panic. Taking deep breaths and upper chest breathing are inefficient breathing techniques; the client with COPD should be encouraged to practice diaphragmatic breathing. Increasing oxygen flow is not necessary because the pulse oximetry is 93%.

The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client

exhale hard and fast with a single blow To use a peak flow meter, the client stands. Then the client takes a deep breath and exhales hard and fast with a single blow. The client repeats this twice and records a "personal best" in an asthma diary.

Which exposure acts as a risk factor for and accounts for the majority of cases of chronic obstructive pulmonary disease (COPD)?

exposure to tobacco smoke Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors but do not account for the majority.

A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client?

increase walking distance around the city block without shortness of breath If the client has mild COPD, goals are to increase exercise and prevent further loss of pulmonary function. The client who increases his walking distance without shortness of breath meets these criteria. If the client has severe COPD, goals are then to preserve current pulmonary function and relieve symptoms as much as possible. Examples of these goals are the other options, in which the activity level is at current and symptoms are relieved to tolerable or close to tolerable.

Which measure may increase complications for a client with COPD?

increased oxygen supply Administering too much oxygen can result in the retention of carbon dioxide. Clients with alveolar hypoventilation cannot increase ventilation to adjust for this increased load, and hypercapnia occurs. All the other measures aim to prevent complications.

A client with symptoms of mild persistent asthma is now initiating treatment. Which of the following is the preferred therapy that the nurse will teach the client to use at home?

inhaled beclomethasone For mild persistent asthma, the preferred treatment is an inhaled corticosteroid, such as beclomethasone (Beconase). The other medications are for long-term control, prevention, or both in moderate to severe persistent asthma.

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should:

instruct the client to drink at least 2L of fluid daily Mobilizing secretions is crucial to maintaining a patent airway and maximizing gas exchange in the client with COPD. Measures that help mobilize secretions include drinking 2 L of fluid daily, practicing controlled pursed-lip breathing, and engaging in moderate activity. Anxiolytics rarely are recommended for the client with COPD because they may cause sedation and subsequent infection from inadequate mobilization of secretions. Because COPD rarely causes pain, pain medication isn't indicated.

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

it helps prevent early airway collapse Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

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 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).

Which diagnostic test is most accurate in assessing acute airway obstruction?

pulmonary function studies Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression. ABGs and pulse oximetry are not the most accurate diagnostics for an airway obstruction. Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of FEV1 to forced vital capacity (FVC).

A client has been classified as status asthmaticus. The nurse understands that this client will likely initially exhibit symptoms of:

respiratory alkalosis 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 health care provider orders a beta-2 adrenergic agonist agent (bronchodilator) that is long-acting and administered only by inhaler. What medication does the nurse anticipate will be administered?

salmeterol Salmeterol is a long-acting inhalant. Terbutaline (Brethine) is a beta-2 adrenergic agonist agent (bronchodilator) that is short-acting and administered by inhaler and oral form. Metaproterenol sulfate (Alupent) is a short-acting beta-2 adrenergic agonist agent, but it may be administered by an inhaler, by a nebulizer, or orally. Formoterol (Foradil) is a long-acting beta-2 adrenergic agonist agent given by inhalant and nebulizer. Isoprenaline (Isuprel) is a beta-2 adrenergic agonist agent, but it may be administered by various routes.

The classification of Stage III of COPD is defined as

severe COPD Stage III is severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage IV is very severe COPD.

A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching? Select all that apply.

status asthmaticus respiratory failure atelectasis Complications of asthma may include status asthmaticus, respiratory failure, and atelectasis. Pertussis is not an asthma complication. Thoracentesis is a diagnostic procedure, not a complication.

Cystic fibrosis (CF) is diagnosed by clinical signs and symptoms in addition to which test?

sweat chloride concentration Diagnosis of CF is based on an elevated sweat chloride concentration, together with clinical signs and symptoms consistent with the disease.

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 decreased overtime in clients with COPD 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 is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include

the importance of taking blood test to monitor serum concentrations The nurse should inform clients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The client is at risk of developing hypokalemia.

The nurse is instructing the patient with asthma in the use of a newly prescribed leukotriene receptor antagonist. What should the nurse be sure to include in the education?

the patient should take the medication an hour before meals or 2 hours after meals The nurse should instruct the patient to take the leukotriene receptor antagonist at least 1 hour before meals or 2 hours after meals.

A commonly prescribed methylxanthine used as a bronchodilator is which of the following?

theophylline Theophylline is an example of a methylxanthine. All the others are examples of inhaled short-acting beta2 agonists.

The nurse is assigned to care for a patient in the ICU who is diagnosed with status asthmaticus. Why does the nurse include fluid intake as being an important aspect of the plan of care? (Select all that apply.)

to combat dehydration to loosen secretions to facilitate expectoration The nurse also assesses the patient's skin turgor for signs of dehydration. Fluid intake is essential to combat dehydration, to loosen secretions, and to facilitate expectoration.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

using venturi mask to deliver oxygen as ordered The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.