Ch 28: Obstructive Pulmonary Diseases

The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? a. Albuterol b. Ipratropium bromide c. Salmeterol (Serevent) d. Beclomethasone (Qvar)

A Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).

While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do? a. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. b. Use the flow meter each morning after taking medications to evaluate their effectiveness. c. Increase the doses of the long-term control medication if the peak flow numbers decrease. d. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

A It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter and should be assessed before and after medications to evaluate their effectiveness.

In evaluating an asthmatic patient's knowledge of self-care, the nurse recognizes that additional instruction is needed when the patient says, a. "I use my corticosteroid inhaler when I feel short of breath." b. "I get a flu shot every year and see my HCP if I have an upper respiratory tract infection." c. "I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies." d. "I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting short of breath."

A Rationale: A rescue plan for patients with asthma includes taking two to four puffs of a short-acting bronchodilator every 20 minutes three times to obtain rapid control of symptoms. Corticosteroids cannot abort an acute asthma attack.

A patient who has bronchiectasis asks the nurse, "What conditions would warrant a call to the clinic?" a. Blood clots in the sputum b. Sticky sputum on a hot day c. Increased shortness of breath after eating a large meal d. Production of large amounts of sputum on a daily basis

A Rationale: If hemoptysis occurs, patients should know when they should contact the HCP. In some patients, a spot of blood is usual. The HCP should give explicit instructions about when emergency contact is needed.

Although a diagnosis of cystic fibrosis (CF) is most often made before age 2 years, an 18-yr-old patient at the student health center with a history of frequent lung and sinus infections has clinical manifestations consistent with undiagnosed CF. Which information would be accurate for the nurse to include when teaching the patient about a scheduled sweat chloride test? a. "Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." b. "The test measures the amount of sodium chloride in your postexercise sweat." c. "If sweating occurs after an oral dose of pilocarpine, the test result for CP is positive." d. "If the sweat chloride test result is positive on two occasions, genetic testing will be necessary."

A The diagnostic criteria for CF involve a combination of clinical presentation, sweat chloride testing, and genetic testing to confirm the diagnosis. The sweat chloride test is performed by placing pilocarpine on the skin and carried by a small electric current to stimulate sweat production. This takes about 5 minutes, and the patient feels a slight tingling or warmth. The sweat is collected on filter paper or gauze and then analyzed for sweat chloride concentrations (for about 1 hour). Values above 60 mmol/L for sweat chloride are consistent with the diagnosis of CF. However, a second sweat chloride test is recommended to confirm the diagnosis, unless genetic testing identifies a CF mutation. Genetic testing is used if the results from a sweat chloride test are unclear.

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? a. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." b. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." c. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." d. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

A The patient should be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.

A male patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? a. Arterial pH 7.26 b. PaCO2 50 mm Hg c. Patient in tripod position d. Increased sputum expectoration

A The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.

The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? a. Wheezing becomes louder. b. Cough remains nonproductive. c. Vesicular breath sounds decrease. d. Aerosol bronchodilators stimulate coughing.

A The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? a. Increasing dyspnea b. Temperature below 98.6°F c. Decreased sputum production d. Unable to drink 3 L of low-sodium fluids

A The significant clinical manifestations to report to the health care provider include increasing dyspnea, fever, chills, increased sputum production, bloody sputum, and chest pain. Although drinking at least 3 L of low-sodium fluid will help liquefy secretions to make them easier to expectorate, the health care provider does not need to be notified if the patient cannot do this one day.

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? a. Work of breathing b. Fear of suffocation c. Effects of medications d. Anxiety and restlessness

A When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.

A 45-yr-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? a. Anxiety b. Cyanosis c. Bradycardia d. Hypercapnia

A An early manifestation during an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply.)? a. Exercise b. Allergies c. Emotional stress d. Decreased humidity e. Upper respiratory infections

A, B, C, E Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychologic factors, and gastroesophageal reflux disease (GERD).

A patient is concerned that he may have asthma. Of the symptoms that he relates to the nurse, which ones suggest asthma or risk factors for asthma (select all that apply)? a. Allergic rhinitis b. Prolonged inhalation c. History of skin allergies d. Cough, especially at night e. Gastric reflux or heartburn

A, C, D, E Rationale: Allergic rhinitis is a major predictor of adult asthma. Allergy skin testing may enable the clinician to determine sensitivity to specific allergens. However, a positive skin test result does not necessarily mean that the allergen is causing the asthma attack, and a negative allergy test result does not mean that the asthma is not allergy related. A radioallergosorbent test (RAST), which is a blood test, is sometimes used to identify allergic causes in certain patients who have negative skin test results and in those who should not be skin tested (e.g., patients with severe eczema). The chronic inflammation of asthma leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning. The exact mechanism by which gastroesophageal reflux disease (GERD) triggers asthma is unknown.

Which treatments in CF would the nurse expect to implement in the management plan of patients with CF (select all that apply)? a. Sperm banking b. IV corticosteroids on a chronic basis c. Airway clearance techniques (e.g., Acapella) d. GoLYTELY given PRN for severe constipation e. Inhaled tobramycin to combat Pseudomonas infection

A, C, D, E Rationale: Nearly all men with cystic fibrosis (CF) have congenital absence of the vas deferens, which transports the sperm from the storage in the testes to the penile urethra. However, sperm may be made normally, and with assisted reproductive technology, they are able to father children. Airway clearance techniques include chest physiotherapy, positive expiratory pressure devices (e.g., Flutter device, Acapella [Fig. 28-15]), breathing exercises, and high-frequency chest wall oscillation systems. Severe constipation can be treated with ingestion of a balanced polyethylene glycol (PEG) electrolyte solution (MiraLax, Go-LYTELY), which is used to thin bowel contents. Inhaled tobramycin is effective in patients with CF who have Pseudomonas aeruginosa infections.

A plan of care for the patient with COPD could include (select all that apply) a. exercise such as walking. b. high flow rate of O2 administration. c. low-dose chronic oral corticosteroid therapy. d. use of peak flow meter to monitor the progression of COPD. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

A, E Rationale: Breathing exercises may assist the patient during rest and activity (e.g., lifting, walking, stair climbing) by decreasing dyspnea, improving oxygenation, and slowing the respiratory rate. The main type of breathing exercise commonly taught is pursed-lip breathing. Walking or other endurance exercises (e.g., cycling) combined with strength training is probably the best intervention to strengthen muscles and improve the endurance of a patient with chronic obstructive pulmonary disease (COPD).

1. A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/min. When explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is less than ___ L/minute

ANS: 320 A PEFR less than 80% of the personal best indicates that the patient is in the yellow zone where changes in therapy are needed to prevent progression of the airway narrowing. DIF: Cognitive Level: Apply (application) REF: 555 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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

ANS: A Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds. DIF: Cognitive Level: Analyze (analysis) REF: 539 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: A Hemoptysis may indicate life-threatening hemorrhage, and should be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 580 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

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

ANS: A The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. DIF: Cognitive Level: Analyze (analysis) REF: 543 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

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

ANS: A The patient's assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time. DIF: Cognitive Level: Analyze (analysis) REF: 546 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: A UAP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions require more education and a scope of practice that licensed practical/vocational nurses (LPN/LVNs) or registered nurses (RNs) would have. DIF: Cognitive Level: Apply (application) REF: 568 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

8. A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about a. 1-antitrypsin testing. b. leukotriene modifiers. c. use of the nicotine patch. d. continuous pulse oximetry.

ANS: A When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in 1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD. DIF: Cognitive Level: Apply (application) REF: 558 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: B A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea. DIF: Cognitive Level: Analyze (analysis) REF: 545 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

14. Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min

ANS: B For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue. DIF: Cognitive Level: Analyze (analysis) REF: 543 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

25. A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate? a. Teach the patient signs of hypoglycemia. b. Have the patient add dietary salt to meals. c. Suggest decreasing intake of dietary fat and calories. d. Instruct the patient about pancreatic enzyme replacements.

ANS: B Added dietary salt is indicated whenever sweating is excessive, such as during hot weather, when fever is present, or from intense physical activity. The management of pancreatic insufficiency includes pancreatic enzyme replacement of lipase, protease, and amylase (e.g., Pancreaze, Creon, Ultresa, Zenpep) administered before each meal and snack. This patient is at risk for hyponatremia based on reported symptoms. Adequate intake of fat, calories, protein, and vitamins is important. Fat-soluble vitamins (vitamins A, D, E, and K) must be supplemented because they are malabsorbed. Use of caloric supplements improves nutritional status. Hyperglycemia caused by pancreatic insufficiency is more likely to occur than hypoglycemia. DIF: Cognitive Level: Apply (application) REF: 579 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? a. Change the O2 flow rate to the highest prescribed rate. b. Teach the patient to use the Flutter airway clearance device. c. Reinforce the ongoing use of pursed-lip breathing techniques. d. Teach the patient about consistent use of inhaled corticosteroids.

ANS: B Airway clearance devices assist with moving mucus into larger airways, where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patient's problem of thick mucus secretions. DIF: Cognitive Level: Analyze (analysis) REF: 578 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: B Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly. DIF: Cognitive Level: Analyze (analysis) REF: 548 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: B Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate intervention is needed. The other information should also be reported, but do not indicate possibly life-threatening complications of omalizumab therapy. DIF: Cognitive Level: Analyze (analysis) REF: 548 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: B High-calorie foods such as ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD. DIF: Cognitive Level: Apply (application) REF: 571 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

22. A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Encourage the patient to sit up at the bedside in a chair and lean forward. c. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. d. Place the patient in the Trendelenburg position with pillows behind the head.

ANS: B Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well. DIF: Cognitive Level: Apply (application) REF: 561 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: B Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive. DIF: Cognitive Level: Apply (application) REF: 554 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important? a. Teach the patient to keep the mask on during meals. b. Keep the air entrainment ports clean and unobstructed. c. Give a high enough flow rate to keep the bag from collapsing. d. Drain moisture condensation from the corrugated tubing every hour.

ANS: B The air entrainment ports regulate the O2 percentage delivered to the patient, so they must be unobstructed. The other options refer to other types of O2 devices. A high O2 flow rate is needed when giving O2by partial rebreather or nonrebreather masks. Draining O2 tubing is necessary when caring for a patient receiving mechanical ventilation. The mask can be removed or changed to a nasal cannula at a prescribed setting when the patient eats. DIF: Cognitive Level: Apply (application) REF: 567 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: B The best way to determine the appropriate O2 flow rate is by monitoring the patient's oxygenation either by arterial blood gases (ABGs) or pulse oximetry. An O2 saturation of 90% indicates adequate blood O2 level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an O2 flow rate of 2 L/min may not be adequate. Because O2 use improves survival rate in patients with COPD, there is no concern about O2 dependency. The patient's perceived dyspnea level may be affected by other factors (e.g., anxiety) besides blood O2 level. DIF: Cognitive Level: Apply (application) REF: 565 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: B The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack. DIF: Cognitive Level: Analyze (apply) REF: 545 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

26. A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best? a. "Are you aware of the normal lifespan for patients with CF?" b. "Would like more information to help you with that decision?" c. "Many women with CF do not have difficulty conceiving children." d. "You will need to have genetic counseling before making a decision."

ANS: B The nurse's initial response should be to assess the patient's knowledge level and need for information. Although the lifespan for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patient's comments. The other responses have accurate information, but the nurse should first assess the patient's understanding about the issues surrounding pregnancy. DIF: Cognitive Level: Apply (application) REF: 576 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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

ANS: B The patient should inhale the medication rapidly. Otherwise the dry particles will stick to the tongue and oral mucosa and not get inhaled into the lungs. Advair Diskus is a dry powder inhaler; shaking is not recommended. Spacers are not used with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient should not huff cough or exhale forcefully after taking Advair in order to keep the medication in the lungs. DIF: Cognitive Level: Apply (application) REF: 552 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

13. The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? a. The patient inhales slowly through the nose. b. The patient puffs up the cheeks while exhaling. c. The patient practices by blowing through a straw. d. The patient's ratio of inhalation to exhalation is 1:3.

ANS: B The patient should relax the facial muscles without puffing the cheeks while doing pursed-lip breathing. The other actions by the patient indicate a good understanding of pursed-lip breathing. DIF: Cognitive Level: Apply (application) REF: 554 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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

ANS: B The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting 2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is also appropriate, but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed. DIF: Cognitive Level: Analyze (analysis) REF: 546 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? a. Complicated grieving related to expectation of death b. Chronic low self-esteem related to physical dependence c. Ineffective coping related to unknown outcome of illness d. Deficient knowledge related to lack of education about COPD

ANS: B The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Although deficient knowledge, complicated grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses. DIF: Cognitive Level: Apply (application) REF: 571 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

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

ANS: C -Blockers such as propranolol can cause bronchospasm in some patients with asthma. The other information will be documented in the health history but does not indicate a need for a change in therapy. DIF: Cognitive Level: Apply (application) REF: 554 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: C A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no family tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis. DIF: Cognitive Level: Apply (application) REF: 557 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the inhaler. b. The patient coughs vigorously after using the inhaler. c. The patient removes the facial mask when misting stops. d. The patient activates the inhaler at the onset of expiration.

ANS: C A nebulizer is used to administer aerosolized medication. A mist is seen when the medication is aerosolized, and when all of the medication has been used, the misting stops. The other options refer to inhaler use. Coughing vigorously after inhaling and activating the inhaler at the onset of expiration are both incorrect techniques when using an inhaler. DIF: Cognitive Level: Apply (application) REF: 551 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

19. Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? a. Schedule the procedure 1 hour after the patient eats. b. Maintain the patient in the lateral position for 20 minutes. c. Give the prescribed albuterol (Ventolin HFA) before the therapy. d. Perform percussion before assisting the patient to the drainage position.

ANS: C Bronchodilators are administered before chest physiotherapy. Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is done while the patient is in the postural drainage position. DIF: Cognitive Level: Apply (application) REF: 569 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: C Bronchodilators are held before spirometry so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should be held before spirometry. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed. DIF: Cognitive Level: Apply (application) REF: 543 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? a. The patient reports a recent 15-lb weight gain. b. The patient denies shortness of breath at present. c. The patient takes cimetidine (Tagamet HB) daily. d. The patient complains of coughing up green mucus.

ANS: C Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not affect whether the theophylline should be administered or not. DIF: Cognitive Level: Apply (application) REF: 549 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? a. Chest pain b. Finger clubbing c. Peripheral edema d. Elevated temperature

ANS: C Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not indicators of cor pulmonale. DIF: Cognitive Level: Apply (application) REF: 560 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

11. A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's intake of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.

ANS: C Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture such as whole grains may take more energy to eat and get absorbed and lead to decreased intake. Although fruits, juices, and minerals are not contraindicated, foods high in protein are a better choice. DIF: Cognitive Level: Apply (application) REF: 571 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: C Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma. DIF: Cognitive Level: Apply (application) REF: 552 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"

ANS: C Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present because they are contraindications for an MRI. DIF: Cognitive Level: Apply (application) REF: 561 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

33. A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? a. Discuss the role of diet in blood glucose control. b. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals.

ANS: C The glucose levels indicate that the patient has developed CF-related diabetes, and insulin therapy is required. Because the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient with CF. DIF: Cognitive Level: Apply (application) REF: 577 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next? a. Increase the dose of the leukotriene inhibitor. b. Teach the patient about the use of oral corticosteroids. c. Administer a bronchodilator and recheck the peak flow. d. Instruct the patient to keep the scheduled follow-up appointment.

ANS: C The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symptoms now and use the bronchodilator. DIF: Cognitive Level: Apply (application) REF: 555 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: C The use of home O2 improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the health care provider rather than increasing the O2 flow rate if dyspnea becomes worse. O2 can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable O2 concentrators. DIF: Cognitive Level: Apply (application) REF: 568 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD. DIF: Cognitive Level: Apply (application) REF: 573 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C Use of accessory muscle indicates that the patient is experiencing respiratory distress, and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required. DIF: Cognitive Level: Analyze (analysis) REF: 545 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: D Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise (80% of the maximal heart rate of 150 beats/min ). DIF: Cognitive Level: Apply (application) REF: 573 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

30. The nurse completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy? a. The patient uses albuterol (Ventolin HFA) before aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases after using the albuterol (Ventolin HFA) inhaler. d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).

ANS: D Long-acting 2-agonists should be used only in patients who also are using an inhaled corticosteroid for long-term control. Salmeterol should not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma. DIF: Cognitive Level: Apply (application) REF: 547 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flow meter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient calls the health care provider when the peak flow is in the green zone. d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.

ANS: D Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting 2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but rather is used for maintenance therapy. DIF: Cognitive Level: Apply (application) REF: 556 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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

ANS: D Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium. DIF: Cognitive Level: Apply (application) REF: 578 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

4. Which information will the nurse include in the asthma teaching plan for a patient being discharged? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

ANS: D Tremors are a common side effect of short-acting 2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers. DIF: Cognitive Level: Apply (application) REF: 550 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? a. "I will pay less for medication because it will last longer." b. "More of the medication will get down into my lungs to help my breathing." c. "Now I will not need to breathe in as deeply when taking the inhaler medications." d. "This device will make it so much easier and faster to take my inhaled medications."

B A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler.

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? a. Order fruits and fruit juices to be offered between meals. b. Order a high-calorie, high-protein diet with six small meals a day. c. Teach the patient to use frozen meals at home that can be microwaved. d. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

B Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day taking in a high-calorie, high-protein diet, with nonprotein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? a. Apical pulse b. Daily weight c. Bowel sounds d. Deep tendon reflexes

B Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient's daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes.

The nurse teaches a 53-yr-old male patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement by the patient to the nurse indicates correct understanding of the instructions? a. "I should not use a spacer device with this inhaler." b. "I will rinse my mouth each time after I use this inhaler." c. "I will feel my breathing improve over the next 2 to 3 days." d. "I should use this inhaler immediately if I have trouble breathing."

B Fluticasone may cause oral candidiasis (thrush). The patient should rinse the mouth with water or mouthwash after use or use a spacer device to prevent oral fungal infections. Fluticasone is an inhaled corticosteroid and it may take 2 weeks of regular use for effects to be evident. This medication is not recommended for an acute asthma attack.

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? a. An overproduction of the antiprotease a1-antitrypsin b. Hyperinflation of alveoli and destruction of alveolar walls c. Hypertrophy and hyperplasia of goblet cells in the bronchi d. Collapse and hypoventilation of the terminal respiratory unit

B In COPD, structural changes include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.

The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? a. "Avoid shaking the inhaler before use." b. "Breathe out slowly before positioning the inhaler." c. "Using a spacer should be avoided for this type of medication." d. "After taking a puff, hold the breath for 30 seconds before exhaling."

B It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose. The inhaler should be shaken well. A spacer may be used. Holding the breath after the inhalation of medication helps keep the medication in the lungs, but 30 seconds will not be possible for a patient with COPD.

The nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? a. Place it in water to see if it floats. b. Keep track of the number of inhalations used. c. Shake the canister while holding it next to the ear. d. Check the indicator line on the side of the canister.

B It is no longer appropriate to see if a canister floats in water or not because this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used (100 puffs/2 puffs each day = 50 days).

Which test result identifies that a patient with asthma is responding to treatment? a. An increase in CO2 levels b. A decreased exhaled nitric oxide c. A decrease in white blood cell count d. An increase in serum bicarbonate levels

B Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in a patient with asthma.

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs? a. Hypertension and pulmonary edema b. Oropharyngeal candidiasis and hoarseness c. Elevation of blood glucose and calcium levels d. Adrenocortical dysfunction and hyperglycemia

B Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.

The effects of cigarette smoking on the respiratory system include a. hypertrophy of capillaries causing hemoptysis. b. hyperplasia of goblet cells and increased production of mucus. c. increased proliferation of cilia and decreased clearance of mucus. d. proliferation of alveolar macrophages to decrease the risk for infection.

B Rationale: The irritating effect of the smoke causes hyperplasia of cells, including goblet cells, which results in increased production of mucus. Smoking reduces the ciliary activity and may cause actual loss of cilia.

A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? a. Oxygen tent b. Venturi mask c. Nasal cannula d. Oxygen-conserving cannula

B The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.

A 68-yr-old patient with bronchiectasis has copious thick respiratory secretions. Which intervention should the nurse add to the plan of care for this patient? a. Use the incentive spirometer for at least 10 breaths every 2 hours. b. Administer prescribed antibiotics and antitussives on a scheduled basis. c. Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. d. Provide nutritional supplements that are high in protein and carbohydrates.

C Adequate hydration helps to liquefy secretions and thus make it easier to remove them. Unless there are contraindications, the nurse should instruct the patient to drink at least 3 L of fluid daily. Although nutrition, breathing exercises, and antibiotics may be indicated, these interventions will not liquefy or thin secretions. Antitussives may reduce the urge to cough and clear sputum, increasing congestion. Expectorants may be used to liquefy and facilitate clearing secretions.

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding? a. Absence of dyspnea b. Improved mental status c. Effective and productive coughing d. PaO2 within normal range for the patient

C Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? a. Temperature of 98.4°F b. Oxygen saturation 96% c. Pulse rate of 72 beats/min d. Respiratory rate of 18/ breaths/min

C Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 beats/min indicates that the patient did not experience tachycardia as an adverse effect.

Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? a. Acute respiratory failure b. Secondary respiratory infection c. Fluid volume excess resulting from cor pulmonale d. Pulmonary edema caused by left-sided heart failure

C Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.

The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium after noting which assessment finding? a. Decreased respiratory rate b. Increased respiratory rate c. Increased peak flow readings d. Decreased sputum production

C Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates.

During an assessment of a 45-yr-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? a. Laryngospasm b. Pulmonary edema c. Narrowing of the airway d. Overdistention of the alveoli

C Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing.

The nurse is caring for a 48-yr-old male patient admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The patient develops severe dyspnea at rest, with a change in respiratory rate from 26 breaths/min to 44 breaths/min. Which action by the nurse would be the most appropriate? a. Have the patient perform huff coughing. b. Perform chest physiotherapy for 5 minutes. c. Teach the patient to use pursed-lip breathing. d. Instruct the patient in diaphragmatic breathing.

C Pursed-lip breathing (PLB) prolongs exhalation and prevents bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn. It also gives the patient more control over breathing. Evidence from controlled studies does not support the use of diaphragmatic breathing in patients with COPD. Diaphragmatic breathing results in hyperinflation because of increased fatigue and dyspnea and abdominal paradoxical breathing rather than with normal chest wall motion. Chest physiotherapy (percussion and vibration) is used primarily for patients with excessive bronchial secretions who have difficulty clearing them. Huff coughing is a technique that helps patients with COPD to use a forced expiratory technique to clear secretions.

The major advantage of a Venturi mask is that it can a. deliver up to 80% O2. b. provide continuous 100% humidity. c. deliver a precise concentration of O2. d. be used while a patient eats and sleeps.

C Rationale: The Venturi mask is a high-flow device that delivers fixed concentrations of O2 (e.g., 24% or 28%, independent of the patient's respiratory pattern).

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a â-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? a. IV fluids b. Biofeedback therapy c. Systemic corticosteroids d. Pulmonary function testing

C Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? a. Smoking causes a hoarse voice. b. Cough will become nonproductive. c. Decreased alveolar macrophage function d. Sense of smell is decreased with smoking.

C The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? a. Allow time to calm the patient. b. Observe for signs of diaphoresis. c. Evaluate the use of intercostal muscles. d. Monitor the patient for bilateral chest expansion.

C The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.

Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? a. Supine b. Lithotomy c. High Fowler's d. Reverse Trendelenburg

C The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.

When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? a. Fat soluble vitamins and dietary salt should be avoided. b. Insulin may be needed with a diabetic diet if diabetes mellitus develops. c. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. d. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.

C The patient must take pancreatic enzymes before each meal and snack and adequate fat, calories, protein, and vitamins should be eaten. Fat-soluble vitamins are needed because they are malabsorbed with the excess mucus in the gastrointestinal system. Insulin may be needed, but there is no longer a diabetic diet, and this is not priority information at this time. DIOS develops in the terminal ileum and is treated with balanced polyethylene glycol electrolyte solution (MiraLAX) to thin bowel contents.

The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? a. Loosening secretions so that they may be coughed up more easily b. Promoting maximal inhalation for better oxygenation of the lungs c. Preventing bronchial collapse and air trapping in the lungs during exhalation d. Increasing the respiratory rate and giving the patient control of respiratory patterns

C The purpose of pursed-lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation. It does not affect secretions, inhalation, or increase the rate of breathing.

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? a. Chew a hard candy before the first puff of medication. b. Rinse the mouth with water before each puff of medication. c. Ask for a breath mint after the second puff of medication. d. Rinse the mouth with water after the second puff of medication.

D Because beclomethasone is a corticosteroid, the patient should rinse the mouth with water after the second puff of medication to reduce the risk of fungal overgrowth and oral infection.

The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/LVN), and unlicensed assistive personnel (UAP) on a medical unit. The team is caring for many patients with respiratory problems. In what situation should the nurse intervene with teaching for a team member? a. LPN/LVN obtained a pulse oximetry reading of 94% but did not report it. b. RN taught the patient about home oxygen safety in preparation for discharge. c. UAP report to the nurse that the patient is complaining of difficulty breathing. d. LPN/LVN changed the type of oxygen device based on arterial blood gas results.

D It is not within the LPN scope to change oxygen devices based on analysis of lab results. It is within the scope of practice of the RN to assess, teach, and evaluate. The LPN provides care for stable patients and may adjust oxygen flow rates depending on desired oxygen saturation levels of stable patients. The UAP may obtain oxygen saturation levels, assist patients with comfort adjustment of oxygen devices, and report changes in patient's level of consciousness or difficulty breathing.

A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? a. "Long-term home oxygen therapy should be used to prevent respiratory failure." b. "Oxygen will not be needed until or unless you are in the terminal stages of this disease." c. "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." d. "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

D Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.

Which guideline would be a part of teaching patients how to use a metered-dose inhaler (MDI)? a. After activating the MDI, breathe in as quickly as you can. b. Estimate the amount of remaining medicine in the MDI by floating the canister in water. c. Disassemble the plastic canister from the inhaler and rinse both pieces under running water every week. d. To determine how long the canister will last, divide the total number of puffs in the canister by the puffs needed per day.

D Rationale: The patient needs to know the correct way to determine if the metered-dose inhaler (MDI) is empty (Fig. 28-6). The patient should divide the total number of puffs in the canister by the puffs needed per day.

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler? a. "I can rinse my mouth following the two puffs to get rid of the bad taste." b. "I should wait at least 1 to 2 minutes between each puff of the inhaler." c. "Because this medication is not fast acting, I cannot use it in an emergency if my breathing gets worse." d. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

D The patient should not just keep taking extra puffs of the inhaler to make breathing easier. Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient's respiratory status. Rinsing the mouth after the puffs will eliminate a bad taste. Waiting 1 to 2 minutes between each puff will facilitate the effectiveness of the administration. Ipratropium is not used in an emergency for COPD.

Before discharge, the nurse discusses activity levels with a 61-yr-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? a. Slightly increase activity over the current level. b. Swim for 10 min/day, gradually increasing to 30 min/day. c. Limit exercise to activities of daily living to conserve energy. d. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

D The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 - patient's age).