COPD & Asthma NCLEX

What causes the pulmonary vasoconstriction leading to the development of cor pulmonale in the patient with COPD? a. Increased viscosity of the blood b. Alveolar hypoxia and hypercapnia c. Long-term low-flow oxygen therapy d. Administration of high concentrations of oxygen

b Constriction of the pulmonary vessels, leading to pulmonary hypertension, is caused by alveolar hypoxia and the acidosis that results from hypercapnia. Polycythemia is a contributing factor in cor pulmonale because it increases the viscosity of blood and the pressure needed to circulate the blood. Long-term low-flow oxygen therapy dilates pulmonary vessels and is used to treat cor pulmonale. High oxygen administration is not related to cor pulmonale.

A client presenting with an acute asthma attack is being assessed in the emergency room. The client's spouse reports that the client currently is being treated for an upper respiratory infection. The nurse should understand that the client most likely has which type of asthma? a. Allergic b. Emotional c. Extrinsic d. Intrinsic

d Intrinsic asthma is triggered by an internal factor such as a cold. Intrinsic asthma does not have an identifiable allergen. Asthma related to emotions is considered as extrinsic asthma. Extrinsic asthma includes allergens such as pet dander, dust mites, mold, dust, etc.

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 non-protein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.

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 α1-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 there are structural changes that 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.

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? a. Teaching how to make a room allergy-free b. Referring to a support group for individuals with asthma c. Arranging with the college to ensure a speedy return to classes d. Evaluating whether the necessary lifestyle changes are understood

d Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

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 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).

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are: pH 7.35; PCO2 62 (8.25 kPa); PO2 70 (9.31 kPa) (34 mmol/L); HCO3 34. The nurse should first: a. Apply a 100% nonrebreather mask. b. Assess the vital signs. c. Reposition the client. d. Prepare for intubation.

b Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation.

The nurse teaches a 33-year-old male patient with asthma how to administer fluticasone (Flovent HFA) 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 hours." d. "I should use this inhaler immediately if I have trouble breathing."

b Fluticasone (Flovent HFA) 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.

A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3-, 36 mEq/L. The nurse should assess the client for: a. Cyanosis. b. Flushed skin. c. Irritability. d. Anxiety.

b The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? a. Perform the procedure once in the morning and once at night b. Move the trunk to an upright position and then exhale while bending over c. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece d. Place the mouthpiece between the lips and in front of the teeth before starting the procedure

c A peak flow meter measures the peak expiratory flow rate, the maximum flow of air that can be forcefully exhaled in one second; this monitors the pulmonary status of a client with asthma. The peak flow measurement should be done daily in the morning before the administration of medication or when experiencing dyspnea. The client should be standing or sitting upright. Placing the mouthpiece between the lips and in front of the teeth before starting the procedure will interfere with an accurate test; the mouthpiece should be in the mouth between the teeth with the lips creating a seal around the mouthpiece.

A client with emphysema should receive only 1 to 3 L/minute of oxygen, if needed, or he may lose his hypoxic drive. Which of the following statements is correct about hypoxic drive? a. The client doesn't notice he needs to breathe. b. The client breathes only when his oxygen levels climb above a certain point. c. The client breathes only when his oxygen levels dip below a certain point. d. The client breathes only when his carbon dioxide level dips below a certain point.

c Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known as the hypoxic drive. They don't take a breath when their levels of carbon dioxide are higher than normal, as do those with healthy respiratory physiology. If too much oxygen is given, the client has little stimulus to take another breath. In the meantime, his carbon dioxide levels continue to climb, and the client will pass out, leading to a respiratory arrest.

A patient is being discharged with plans for home O2 therapy provided by an O2 concentrator with an O2-conserving portable unit. In preparing the patient to use the equipment, what should the nurse teach the patient? a. The portable unit will last about 6 to 8 hours. b. The unit is strictly for portable and emergency use. c. The unit concentrates O2 from the air, providing a continuous O2 supply. d. Weekly delivery of one large cylinder of O2 will be necessary for a 7- to 10-day supply of O2.

c Oxygen concentrators or extractors continuously supply O2 concentrated from the air. O2-conserving units will last for up to 20 hours. Portable liquid O2 units will hold about 6 to 8 hours of O2 but because of the expense they are only used for portable and emergency use. Compressed O2 comes in various tank sizes but generally it requires weekly deliveries of four to five large tanks to meet a 7- to 10-day supply.

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.

During an acute exacerbation of mild COPD, the patient is severely short of breath and the nurse identifies a nursing diagnosis of ineffective breathing pattern related to obstruction of airflow and anxiety. What is the best action by the nurse? a. Prepare and administer routine bronchodilator medications. b. Perform chest physiotherapy to promote removal of secretions. c. Administer oxygen at 5 L/min until the shortness of breath is relieved. d. Position the patient upright with the elbows resting on the over-the-bed table.

d The tripod position with an elevated backrest and supported upper extremities to fix the shoulder girdle maximizes respiratory excursion and an effective breathing pattern. Staying with the patient and encouraging pursed lip breathing also helps. Bronchodilators may help but can also increase nervousness and anxiety; rescue inhalers would be used before routine bronchodilators. Postural drainage is not tolerated by a patient in acute respiratory distress and oxygen is titrated to an effective rate based on ABGs because of the possibility of carbon dioxide narcosis.

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon wakening in the morning. The nurse should suggest that the client: a. Use a humidifier in the bedroom b. Sleep with two or more pillows c. Cough regularly even if the cough does not produce sputum d. Cough and deep breathe each night before going to sleep

a A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early morning congestion.

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

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

Exercise has which of the following effects on clients with asthma, chronic bronchitis, and emphysema? a. It enhances cardiovascular fitness. b. It improves respiratory muscle strength. c. It reduces the number of acute attacks. d. It worsens respiratory function and is discouraged.

a Exercise can improve cardiovascular fitness and help the client tolerate periods of hypoxia better, perhaps reducing the risk of heart attack. Most exercise has little effect on respiratory muscle strength, and these clients can't tolerate the type of exercise necessary to do this. Exercise won't reduce the number of acute attacks. In some instances, exercise may be contraindicated, and the client should check with his physician before starting any exercise program.

A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol? a. Irregular heartbeat. b. Constipation. c. Pedal edema. d. Decreased pulse rate.

a Irregular heartbeats should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders.

Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons best explains why? a. Reducing fluid volume reduces oxygen demand. b. Reducing fluid volume improves clients' mobility. c. Restricting fluid volume reduces sputum production. d. Reducing fluid volume improves respiratory function.

a Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand and, in turn, reduces the respiratory rate. It may also reduce edema and improve mobility a little, but exercise tolerance will still be harder to clear airways. Reducing fluid volume won't improve respiratory function, but may improve oxygenation.

"The client with chronic obstructive pulmonary disease (COPD) is taking theophylline. The nurse should instruct the client to report which of the following signs of theophylline toxicity? Select all that apply. a. Nausea. b. Vomiting. c. Seizures. d. Insomnia. e. Vision changes.

a, b, c, d The therapeutic range for serum theophylline is 10 to 20 mcg/mL (55.5 to 111 μmol/L). At higher levels, the client will experience signs of toxicity such as nausea, vomiting, seizure, and insomnia.

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 should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack? a. Occupational exposure to toxins. b. Viral respiratory infections. c. Exposure to cigarette smoke. d. Exercising in cold temperatures.

b The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacks are triggered by exercising in cold weather.

What is an indication of marked bronchoconstriction with air trapping and hyperinflation of the lungs in a patient with asthma? a. SaO2 of 85% b. PEF rate of <150 L/min c. FEV1 of 85% of predicted d. Chest x-ray showing a flattened diaphragm

b Peak expiratory flow rates (PEFR) are normally up to 600 L/min and in status asthmaticus may be as low as 100 to 150 L/min. An SaO2 of 85% and a FEV1 of 85% of predicted are typical of mild to moderate asthma. A flattened diaphragm may be present in the patient with long-standing asthma but does not reflect current bronchoconstriction.

Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? a. The client promises to do pursed-lip breathing at home. b. The client states actions to reduce pain. c. The client will use oxygen via a nasal cannula at 5 L/min. d. The client agrees to call the physician if dyspnea on exertion increases.

4 Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/min) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse assess first? a. Cyanosis b. Bradycardia c. Mental confusion d. Distended neck veins

c Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

A patient with asthma has the following arterial blood gas (ABG) results early in an acute asthma attack: pH 7.48, PaCO2 30 mm Hg, PaO2 78 mm Hg. What is the most appropriate action by the nurse? a. Prepare the patient for mechanical ventilation. b. Have the patient breathe in a paper bag to raise the PaCO2. c. Document the findings and monitor the ABGs for a trend toward alkalosis. d. Reduce the patient's oxygen flow rate to keep the PaO2 at the current level.

c Early in an asthma attack, an increased respiratory rate and hyperventilation create a respiratory alkalosis with increased pH and decreased PaCO2, accompanied by hypoxemia. As the attack progresses, pH shifts to normal, then decreases, with arterial blood gases (ABGs) that reflect respiratory acidosis with hypoxemia. During the attack, high-flow oxygen should be provided. Breathing in a paper bag, although used to treat some types of hyperventilation, would increase the hypoxemia.

Rehabilitation of a client with chronic obstructive pulmonary disease (COPD) involves strategies to decrease hospital admissions and to live a more active life. What should the nurse teach the client to do? a. Initiate activities to eliminate infection. b. Inhale during movements that require energy. c. Implement breathing that uses the thoracic muscles. d. Incorporate humidification into the home environment.

d Humidification of the environment helps to prevent thickened secretions. Liquefied secretions are easier to expectorate. Measures to prevent infection are essential; however, infections are impossible to eliminate. Exhaling requires less energy than inhaling; therefore, movements that use energy should be done during exhalation. The use of abdominal muscles rather than thoracic muscles improves the client's breathing.c

Which medication is a dry powder inhaler (DPI) that is used only for COPD? a. Roflumilast (Daliresp) b. Salmeterol (Serevent) c. Ipratropium (Atrovent HFA) d. Indacterol (Arcapta Neohaler)

d Indacterol (Arcapta Neohaler) is a DPI that is used only for COPD. Roflumilast (Daliresp) is an oral medication used for COPD. Salmeterol (Serevent) is a DPI but it is also used in asthma with inhaled corticosteroids. Ipratropium (Atrovent HFA) is used for COPD but it is delivered via metered-dose inhaler or nebulizer.

A patient has been receiving oxygen per nasal cannula while hospitalized for 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.

When teaching the patient about going from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI), which statement by the patient shows the nurse that the patient needs more teaching? a. "I do not need to use the spacer like I used to." b. "I will hold my breath for 10 seconds or longer if I can." c. "I will not shake this inhaler like I did with my old inhaler." d. "I will store it in the bathroom so I will be able to clean it when I need to."

d Storing the dry powder inhaler (DPI) in the bathroom will expose it to moisture, which could cause clumping of the medication and an altered dose. The other statements show patient understanding.

Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop? a. Atelectasis b. Bronchiectasis c. Effusion d. Inflammation

d The most common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Atelectasis and brochiectasis indicate a collapse of a portion of the airway that doesn't occur with pneumonia. An effusion is an accumulation of excess pleural fluid in the pleural space, which may be a secondary response to pneumonia.

The nurse is caring for a patient with an acute exacerbation of asthma. Following 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 developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to: a. Develop respiratory infections easily. b. Maintain current status. c. Require less supplemental oxygen. d. Show permanent improvement.

a A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.