Asthma
The nurse is auscultating the lungs of an asthmatic client during an acute attack. Which is the correct technique that the nurse should use during this assessment? A. Ask the client to breathe in and out rapidly through the mouth while auscultating each location. B. Listen as the client inhales, and then move to the next site on the thorax during exhalation. C. Auscultate for at least one full respiration in each location on the thorax. D. Auscultate the anterior and posterior thorax over the client's hospital gown.
Auscultate for at least one full respiration in each location on the thorax. Rationale: During auscultation of the thorax with a stethoscope, it is important to listen to one full respiration in each location. The stethoscope should be placed on the client's skin, not over the gown, and the client should be asked to take slow, deep breaths in and out while offering times for the client to breathe normally to prevent possible dizziness.
A client who is experiencing an acute asthma attack is brought to the emergency department. Which action should the nurse take first? A. Obtain a peak flowmeter reading. B. Administer an inhaled corticosteroid. C. Auscultate the client's lungs. D. Determine when the shortness of breath began.
Auscultate the client's lungs. Rationale: Assessment of the client's lungs will help determine how effectively the client is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the current status. During an acute attack, most clients are unable to use a peak flowmeter. Medication administration should be done following the assessment.
The nurse is caring for a client diagnosed with status asthmaticus who is currently not receiving any medical treatment. Which risk factor should the nurse consider for this client? (Select all that apply.) A. Hyporeflexia B. Hyperresonance C. Alkalosis D. Anxiety E. Hypercapnia
Hyperresonance Anxiety Hypercapnia Rationale: The client who is not being treated for status asthmaticus is at risk for developing hypercapnia, hyperresonance, and anxiety. Acidosis occurs with status asthmaticus, not alkalosis. Hyporeflexia is not a condition that occurs if a client does not receive treatment for status asthmaticus.
A pediatric client who has asthma is unable to speak, has shortness of breath, and has diminished breath sounds. Which type of asthma exacerbation is the client experiencing based on the assessment findings? A. Minimal B. Severe C. Moderate D. Mild
severe Rationale: This client is experiencing a severe asthma exacerbation with the assessment findings of shortness of breath, being unable to speak, and diminished breath sounds. A moderate exacerbation is manifested by shortness of breath at rest, the ability to speak in single words, and biphasic wheezing. A mild exacerbation is manifested by shortness of breath with mild exertion, the ability to speak in phrases, and audible expiratory wheezing. A minimal asthma attack is manifested by shortness of breath on exertion, the ability to speak in sentences, and wheezing being noted on auscultation.
The nurse is teaching a client who is newly diagnosed with asthma. Which manifestation of an asthma attack should the nurse include? A. Wheezing B. Headache C. Bradycardia D. Chest pain
wheezing Rationale: Wheezing occurs in asthma due to narrowing of airways. Chest pain and headaches are not a part of an asthma attack. Clients might exhibit tachycardia with an asthma attack, not bradycardia.
A client with acute shortness of breath is brought to the emergency department. Which action should the nurse take during the initial assessment? A. Assess for allergies before treatment. B. Place the client supine to complete a full physical assessment. C. Complete pulmonary function testing. D. Briefly ask specific questions about the client's current respiratory status.
Briefly ask specific questions about the client's current respiratory status. Rationale: Since the client has severe respiratory distress, only information that is pertinent to the current respiratory status is obtained, and a more thorough assessment is deferred until later. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Having the client lie down is contraindicated due to the respiratory distress. Obtaining a full physical examination is unnecessary until the acute distress has resolved. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
The nurse is examining a client newly diagnosed with asthma. Which pathological characteristic should the nurse expect in this client during physical examination? A. Expiratory wheezing B. Increased lung volume C. Air trapping D. Dead space
Expiratory wheezing Rationale: On physical examination, there is expiratory wheezing that is often described as high pitched and musical, and there is prolongation of the expiratory phase of the respiratory cycle. Lung volumes are decreased. Air trapping and dead space occur in emphysema, not asthma.
The nurse is discharging a client following a status asthmaticus episode. Which information should the nurse include in the asthma-teaching plan to prevent recurrence of episodes? (Select all that apply.) A. Getting a yearly influenza vaccination B. Using the inhaled corticosteroid when shortness of breath occurs C. Recommending that the client not be vaccinated for pneumonia D. Avoiding breathing in strong odors and smoke E. Carrying a rapid-acting bronchodilator inhaler at all times
Getting a yearly influenza vaccination Avoiding breathing in strong odors and smoke Carrying a rapid-acting bronchodilator inhaler at all times Rationale: Clients should be instructed to get vaccinated for both influenza and pneumonia and avoid asthma triggers such as strong odors and smoke. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid-acting bronchodilators are used to quickly open airways in an asthma attack and should be carried with the client at all times.
Which intervention is appropriate for the nurse to implement for a client who is short of breath? (Select all that apply.) A. Monitor skin color and temperature. B. Administer oxygen as prescribed. C. Monitor level of consciousness. D. Provide endotracheal suctioning as needed. E. Place the client in the prone position.
Monitor skin color and temperature. Administer oxygen as prescribed. Monitor level of consciousness. Provide endotracheal suctioning as needed. Rationale: Interventions to address the problem of shortness of breath in clients who have asthma include monitoring skin color and temperature, monitoring level of consciousness, administering oxygen as prescribed, and providing endotracheal suctioning as needed. Other interventions include placing the client in high Fowler position, or the orthopneic position, but not the prone position.
The nurse is evaluating the effectiveness of therapy for a client following treatment for an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? A. Capillary refill is 2 seconds. B. Oxygen saturation is 96%. C. Respiratory rate is 18 breaths/min. D. No wheezing.
Oxygen saturation is 96%. Rationale: The goal for treatment of an asthma attack is to keep the oxygen saturation greater than 90%, so the reading of 96% indicates that the therapy has been effective. No wheezing heard on auscultation does not indicate good ventilation or oxygenation. The respiratory rate and capillary refill time appear within normal limits; however, these data can also occur when the client is too fatigued to continue with the increased work of breathing that is required in an asthma attack.
A client is admitted in the emergency department for asthma. Which diagnostic and lab test should the nurse expect to be ordered? (Select all that apply.) A. Peak expiratory flow B. Arterial blood gas C. Spirometry D. Allergy skin testing E. Pulse oximetry
Peak expiratory flow Arterial blood gas Allergy skin testing Pulse oximetry Rationale: Diagnostic tests that are appropriate for a client with asthma include peak expiratory flow, pulse oximetry, allergy skin testing, and arterial blood gas analysis. Spirometry can determine the extent of bronchospasm in clients with bronchitis, but not with asthma.
A client with a history of asthma presents with bradycardia and severe wheezing. Which action should be the nurse's priority? A. Preparing to assist with intubation and mechanical ventilation B. Encouraging the client to cough and breathe deeply C. Auscultating the lungs D. Administering an intravenous (IV) corticosteroid
Preparing to assist with intubation and mechanical ventilation Rationale: The client's clinical manifestation indicates impending respiratory failure and immediate action is required, so the nurse should notify the healthcare provider. The nurse should prepare to assist with intubation and mechanical ventilation after notifying the healthcare provider. IV corticosteroids require several hours before having any effect on respiratory status. Auscultation, coughing, and deep breathing will not help this client.
The nurse is evaluating the oxygenation status of a client during an asthma attack. Which diagnostic tool should be most useful for gathering this information? A. Peak flowmeter B. Chest x-ray C. Cardiac monitor D. Pulse oximetry
Pulse oximetry Rationale: The nurse should use pulse oximetry to determine the client's oxygen saturation. The goal for treatment of an asthma attack is to keep the oxygen saturation greater than 90%. Viewing the heart rate and rhythm, chest x-ray, and knowing the measurements for the peak flow reading do not indicate if the client has good oxygenation status.
Which clinical manifestation should the nurse expect to observe in the client with asthma? (Select all that apply.) A. Bradycardia B. Retractions C. Dyspnea D. Wheezing E. Cough
Retractions Dyspnea Wheezing Cough Rationale: Clinical manifestations associated with asthma include dyspnea, wheezing, cough, and retractions. Tachycardia, not bradycardia, is a clinical manifestation of asthma. OK
The nurse is preparing to teach a client who is newly diagnosed with asthma on how to prevent asthma triggers. Which trigger should the nurse include in the teaching plan? (Select all that apply.) A. Stuffed animals B. Cigarette smoke C. Indoor pets D. Tile floors in the house E. Mattress covers
Stuffed animals Cigarette smoke Indoor pets Rationale: Asthma triggers include cigarette smoke, indoor pets, and stuffed animals. Carpets, not tile floors, should be avoided as they can trigger asthma. Mattress covers should be used to decrease dust mites, which is a trigger for asthma.
A client has been taught how to use a peak flowmeter at home for asthma control. The daily peak flow is 75% of the baseline. Which action should the client take in this situation? A. Contact the healthcare provider. B. Go to the nearest emergency department for an evaluation. C. Take her bronchodilator and recheck the peak flow. D. Increase the dosage of daily corticosteroid and monitor her breathing.
Take her bronchodilator and recheck the peak flow. Rationale: The client's peak flow reading indicates that the condition is worsening, so she should take her bronchodilator and recheck the peak flow. Depending on whether she returns to the green zone, indicating well-controlled symptoms, or worsening to the red zone, the next step will be decided. If the symptoms continue to worsen, she should contact the healthcare provider or go to the emergency department. Increasing the dose of prescribed oral corticosteroid is not an appropriate treatment at this time.
The nurse is completing an admission history on a client with hypertension and possible asthma who is experiencing a new onset of wheezing and shortness of breath. Which information from the client's health history may identify the cause of the asthma attack? A. The client started a nonsteroidal anti-inflammatory drug (NSAID) 1 hour prior. B. The client took two acetaminophen (Tylenol) tablets for a headache that morning. C. The client visited the zoo yesterday. D. Two weeks ago, the client had an influenza vaccination.
The client started a nonsteroidal anti-inflammatory drug (NSAID) 1 hour prior. Rationale: Exposure to aspirin and nonsteroidal anti-inflammatory drugs can cause asthma. The other information in the health history, such as taking acetaminophen and getting an influenza vaccination, will not cause the asthma attack. If the trip to the zoo were going to trigger an attack, it would have happened yesterday while at the zoo or later in the evening following the trip.
The nurse is teaching a client with asthma about peak flowmeter use. Which action by the client indicates that the teaching was successful? A. The client uses the albuterol inhaler for peak flow readings in the yellow zone. B. The client exhales slowly into the mouthpiece to obtain a reading. C. The client plans to contact the healthcare provider when the readings are in the green zone. D. The client anticipates using montelukast for readings in the red zone.
The client uses the albuterol inhaler for peak flow readings in the yellow zone. Rationale: Readings in the yellow zone indicate a decrease in peak flow that should be treated with a short-acting beta2-adrenergic medication such as albuterol. Readings in the green zone indicate good asthma control, so there is no need to contact the healthcare provider. The client should be taught to exhale quickly and forcefully through the peak flowmeter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the client should take a fast-acting bronchodilator and call the healthcare provider for further instructions. Montelukast is not indicated for acute attacks but rather is used for maintenance therapy.
A client calls the clinic nurse and reports the following readings: baseline peak flow of 600 L/min and the current peak flow of 420 L/min. Which instruction should the nurse give this client? A. Avoid any asthma triggers and repeat the peak flow testing. B. Use the albuterol (bronchodilator) inhaler. C. Go to the closest emergency department. D. Notify the healthcare provider.
Use the albuterol (bronchodilator) inhaler. Rationale: The client's peak flow is 70% of normal, which is the yellow zone. This indicates a need for immediate use of short-acting beta-adrenergic medications. Advising the client to avoid exposure to allergens is important but would not address the current decrease in peak flow. Because the client is currently in the yellow zone, notifying the healthcare provider and hospitalization are not immediately needed.
The nurse is discharging a client who is newly diagnosed with asthma. Which topic should the nurse include in the discharge teaching? (Select all that apply.) A. When to contact the healthcare provider B. Side effects of theophylline C. Self-administration of inhaled corticosteroids D. How to use a peak flowmeter E. Complications associated with oxygen therapy
When to contact the healthcare provider Self-administration of inhaled corticosteroids How to use a peak flowmeter Rationale: The nurse should teach the client the use of the peak flowmeter and when to contact the healthcare provider. The use of inhaled corticosteroids is more effective in improving asthma than any other drug and is indicated for all clients with persistent asthma. The other therapies, such as oxygen and theophylline, are not expected treatments for asthma.