Chapter 11: Nursing Management: Patients With Chronic Obstructive Pulmonary Disease and Asthma

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

Exhales hard and fast with a single blow Explanation: 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.

A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is:

"Have you tried to quit smoking before?" Explanation: All the options are appropriate statements; however, the nurse needs to assess the client's statement further. Assessment data include information about previous attempts to quit smoking.

The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction?

"I can't use a spacer or holding chamber with the MDI." Explanation: The client can use a spacer or a holding chamber to facilitate the ease of medication administration. The remaining client statements are accurate and indicate the client understands how to use the MDI correctly.

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 122/82, HR 102, R 24, noted barrel chest, temperature 98.4 °F (36.9 °C) -Client states, "It always seems like I just can't catch my breath." -Pale, paper-thin skin, O2 at 2L/min via nasal cannula -BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C)

-BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C) Explanation: 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 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 -Pertussis -Atelectasis -Thoracentesis

-Status asthmaticus -Respiratory failure -Atelectasis Explanation: 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.

A nurse is administering supplemental oxygen to a client with COPD. The nurse assesses the oxygen saturation level to evaluate the client's status. Which reading would the nurse identify as being appropriate to reduce the risk of vital organ damage in this client?

92% Explanation: Adequate oxygenation of clients (keeping the oxygen saturation at or above 90%) is important to prevent vital organ damage while monitoring for any possible complications of oxygen supplementation. Thus, an oxygen saturation level of 92% would be best.

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. Explanation: 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.

The school nurse is caring for a 10-year-old girl who is having an asthma attack on the school ground at recess. What is the preferred treatment to alleviate this patient's current airflow obstruction?

Beta-adrenergics Explanation: Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medication.

Asthma is cause by which type of response?

IgE-mediated Explanation: Atopy, the genetic predisposition for the development of an IgE-mediated response to allergens, is the most common identifiable predisposing factor for asthma. Chronic exposure to airway allergens may sensitize IgE antibodies and the cells of the airway.

Which measure may increase complications for a client with COPD?

Increased oxygen supply Explanation: 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.

Which of the following is the key underlying feature of asthma?

Inflammation Explanation: Inflammation is the key underlying feature and leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheeze, and dyspnea.

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?

Lung sounds Explanation: A client with COPD is at risk for developing pneumothorax. The description given is consistent with possible pneumothorax. Though the nurse will assess all the data, auscultating the lung sounds will provide the nurse with the information if the client has a pneumothorax.

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 Explanation: 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).

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 a meal. Explanation: The nurse should instruct the patient to take the leukotriene receptor antagonist at least 1 hour before meals or 2 hours after meals.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis. Explanation: In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

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 2 L of fluid daily. Explanation: 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.

The nurse is caring for an asthmatic patient hospitalized with an acute asthma exacerbation. What drugs would the nurse anticipate being ordered for this patient to gain underlying control of persistent asthma?

Anti-inflammatory drugs Explanation: Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the control of persistent asthma.

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 Explanation: 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.

The admitting nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse the need to monitor the patient for what related signs and symptoms?

Dyspnea and hypoxemia Explanation: These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Clubbing of the fingers is not a sign of COPD. Cyanosis is a sign of hypoxemia.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply. -Compromised gas exchange -Decreased airflow -Wheezes Jugular vein distention Ascites

-Compromised gas exchange -Decreased airflow -Wheezes Explanation: Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2015).

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply. -Inflamed airways that obstruct airflow -Mucus secretions that block airways -Overinflated alveoli that impair gas exchange -Dry airways that obstruct airflow -Decreased numbers of goblet cells

-Inflamed airways that obstruct airflow -Mucus secretions that block airways -Overinflated alveoli that impair gas exchange Explanation: Because of chronic inflammation and the body's attempts to repair it, changes and narrowing occur in the airways. In the proximal airways, changes include increased numbers of goblet cells and enlarged submucosal glands, both of which lead to hypersecretion of mucus. In the peripheral airways, inflammation causes thickening of the airway wall, peribronchial fibrosis, exudate in the airway, and overall airway narrowing.

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. Explanation: 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.

A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive treatment is indicated. What is the first action by the nurse?

Collects sputum for culture and sensitivity Explanation: Aggressive therapy for cystic fibrosis involves airway clearance and antibiotics, such as vancomycin and tobramycin, which will be prescribed based on sputum cultures. Sputum must be obtained prior to antibiotic therapy so results will not be skewed. Administering oral pancreatic enzymes with meals will be a lesser priority.

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

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

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

An inhaled beta2-adrenergic agonist Explanation: 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.