D118 Primary Care (Adult): Respiratory

Which statement by the healthcare professional accurately describes asthma? a. An obstructive airway disease characterized by reversible airflow obstruction, bronchial hyperreactivity, and inflammation b. A pulmonary disease characterized by severe hypoxemia, decreased pulmonary compliance, and diffuse densities on chest x-ray imaging c. A pulmonary disorder involving an abnormal expression of a protein, producing viscous mucus that lines the airways, pancreas, sweat ducts, and vas deferens d. An obstructive airway disease characterized by atelectasis and increased pulmonary resistance as a result of a surfactant deficiency

ANS: A Asthma is an obstructive airway disease characterized by reversible airflow obstruction, bronchial hyperreactivity, and inflammation. A disease with severe hypoxemia, decreased compliance, and diffuse densities on chest x-ray is ARDS. The viscous mucus lining the airways and other organs and tissues is seen in cystic fibrosis. Surfactant deficiency is found in RDS of the newborn.

A patient diagnosed with asthma calls the provider to report having a peak flow measure of 75%, shortness of breath, wheezing, and cough, and tells the provider that the symptoms have not improved significantly after a dose of albuterol. The patient uses an inhaled corticosteroid medication twice daily. What will the provider recommend? a. Administering two more doses of albuterol b. Coming to the clinic for evaluation c. Going to the emergency department (ED) d. Taking an oral corticosteroid

ANS: A The patient is experiencing an asthma exacerbation and should follow the asthma action plan (AAP) which recommends three doses of albuterol before reassessing. The peak flow is above 70%, so ED admission is not indicated. The patient may be instructed to come to the clinic for oxygen saturation and spirometry evaluation after administering the albuterol. An oral corticosteroid may be prescribed if the patient will be treated as an outpatient after following the AAP.

The parents of a child with asthma ask the nurse why their child cannot use oral corticosteroids more often, because they are so effective. The nurse will offer which information that is true for children? a. Chronic steroid use can inhibit growth. b. Frequent use of this drug may lead to a decreased response. c. A hypersensitivity reaction to this drug may occur. d. Systemic steroids are more toxic in children.

ANS: A A specific age-related reaction to a drug is growth suppression caused by glucocorticoids. Children with asthma may need these from time to time for acute exacerbations, but chronic use is not recommended. None of the other three effects occurs in either adults or children.DIF: Cognitive Level: ApplicationREF: p. 67TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

An APRN is teaching a patient, who has a peanut allergy, how to use an Epi-Pen. Which statement by the patient indicates understanding of the teaching? a. "After using the Epi-Pen, we must go to the emergency department." b. "The Epi-Pen should be stored in the refrigerator, because epinephrine is sensitive to heat." c. "The teacher should call us when symptoms start so that we can bring the Epi-Pen to school." d. "We should jab the device into the thigh until it is empty of solution."

ANS: A After using the Epi-Pen, it is important that the individual get medical attention as quickly as possible. The effects of epinephrine fade in 10 to 20 minutes, and the anaphylactic reaction can be biphasic and prolonged. Epinephrine is sensitive to heat, but storing the device in the refrigerator can compromise the injection mechanism; the device should be stored at room temperature in a dark place. Individuals who need an Epi-Pen must have the device with them at all times; any delay in treatment can be fatal, because anaphylaxis can occur within minutes after exposure. The EpiPen contains 2 mL of epinephrine, but only 0.3 mL is injected; the device will not be empty with a successful injection.DIF: Cognitive Level: ApplicationREF: pp. 116TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A nurse is caring for a patient who has been taking low-dose aspirin for several days. The nurse notes that the patient has copious amounts of watery nasal secretions and an urticarial rash. The nurse will contact the provider to discuss: a. administering epinephrine. b. changing to a first-generation NSAID. c. reducing the dose of aspirin. d. giving an antihistamine.

ANS: A Aspirin can cause a hypersensitivity reaction in some patients. This may start with profuse watery rhinorrhea and progress to generalized urticaria, bronchospasm, laryngeal edema, and shock. It is not a true anaphylactic reaction, because it is not mediated by the immune system. Epinephrine is the treatment of choice. Patients with sensitivity to ASA often also have sensitivity to NSAIDs; the first indication with this patient is to treat the potential life-threatening effect, not to change the medication. Reduction of the dose of ASA is not indicated, because this reaction is not dose dependent. Antihistamines are not effective, because this is not an allergic reaction.DIF: Cognitive Level: ApplicationREF: p. 608TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A healthcare professional is educating a patient on asthma. The professional tells the patient that the most successful treatment for chronic asthma begins with which action? a. Avoidance of the causative agent b. Administration of broad-spectrum antibiotics c. Administration of drugs that reduce bronchospasm d. Administration of drugs that decrease airway inflammation

ANS: A Chronic management of asthma begins with the avoidance of allergens and other triggers. The need for other treatments is reliant on the avoidance of triggers.

A patient with severe, chronic COPD uses an inhaled LABA/glucocorticoid but continues to have frequent exacerbation of symptoms. The nurse will contact the provider to discuss: a. adding roflumilast [Daliresp] once daily. b. changing to oral theophylline twice daily. c. prescribing oral steroids once daily. d. Using an ipratropium/albuterol combination twice daily.

ANS: A For patients with chronic, severe COPD, the risk of exacerbations may be reduced with roflumilast. Theophylline is used only when other bronchodilators are not effective. Oral steroids are not indicated for this use. Ipratropium is used to treat bronchospasm in COPD.DIF: Cognitive Level: AnalysisREF: p. 691TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient with stable COPD is prescribed a bronchodilator medication. Which type of bronchodilator is preferred for this patient? a. A long-acting inhaled beta2 agonist b. An oral beta2 agonist c. A short-acting beta2 agonist d. An intravenous methylxanthine

ANS: A LABAs are preferred over SABAs for COPD. Oral beta2 agonists are not first-line therapy. Although theophylline, a methylxanthine, was once standard therapy in COPD, it is no longer recommended. It is used only if beta2 agonists are not available.DIF: Cognitive Level: ApplicationREF: p. 690TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient reports loud snoring, fragmented sleep, chronic daytime sleepiness, and fatigue. What treatment does the healthcare professional anticipate teaching this patient about? a. Continuous positive airway pressure while sleeping b. Eventual adenotonsillectomy c. Occupational assessment for safety d. Administration of nightly gabapentin

ANS: A Obstructive sleep apnea syndrome is characterized by repetitive increases in resistance to airflow within the upper airway with loud snoring, gasping, intervals of apnea lasting from 10 to 30 seconds, fragmented sleep, and chronic daytime sleepiness and fatigue, as well as a decrease in oxygen saturation. The treatment of choice is the use of a continuous positive airway pressure machine (CPAP). Adenotonsillectomy is the treatment of choice for children who have sleep apnea related to adenotonsillar hypertrophy. Occupational safety assessment might be important for patients with narcolepsy or who experience microsleeps in which the person does not realize they are falling asleep. Gabapentin is a treatment for restless leg syndrome.

A patient is diagnosed with chronic obstructive pulmonary disease (COPD) and has elevated pulmonary vascular resistance. Which complication would the health care professional assess the patient for? a. Right heart failure b. Left heart failure c. Restrictive cardiomyopathy d. Hypertrophic cardiomyopathy

ANS: A Right heart failure is most often caused by left heart failure, but if it occurs in isolation it is usually due to pulmonary conditions such as pulmonary hypertension, COPD, or cystic fibrosis. The professional would assess the patient for this condition at healthcare visits. Eventually the left side of the heart will fail if right-sided failure is left untreated. Restrictive cardiomyopathy is caused by infiltrative diseases. Hypertrophic cardiomyopathy is caused by hypertension.

A patient who has chronic allergies takes loratadine [Claritin] and develops a severe reaction to bee stings. The patient asks the nurse why the antihistamine did not prevent the reaction. What will the nurse say? a. "Allergy symptoms that are severe are caused by mediators other than histamine." b. "H1 blockers do not prevent the release of histamine from mast cells and basophils." c. "Second-generation H1 blockers contain less active drug and do not work in severe reactions." d. "Severe allergic reactions occur through actions on muscarinic receptors."

ANS: A Severe allergic reactions with symptoms of anaphylaxis are caused by mediators other than histamine, so the benefits of antihistamines are limited. H1 blockers do not block the release of histamine, but this is why they are not effective in anaphylaxis. Second-generation agents are as effective as first-generation agents in allergic reactions mediated by histamine; neither is effective for treating anaphylaxis.DIF: Cognitive Level: ApplicationREF: p. 598TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient with asthma uses albuterol [Ventolin] for wheezing. The nurse assesses the patient and notes vital signs of HR, 96 beats/minute; RR, 18 breaths/minute; and BP, 116/78 mmHg. The patient has clear breath sounds and hand tremors. What will the nurse do? a. Ask the patient how often the inhaler is used. b. Check the patient's blood glucose level. c. Request an order for isoproterenol [Isuprel] to reduce side effects. d. Stop the medication and report the tremors to the provider.

ANS: A Tachycardia is a response to activation of beta1 receptors. It can occur when large doses of albuterol are used and selectivity decreases. The nurse should question the patient about the number of inhalations used. Isoproterenol can cause hyperglycemia in diabetic patients. Isoproterenol has more side effects than albuterol. Tremors are an expected side effect and are not an indication for stopping the drug.DIF: Cognitive Level: ApplicationREF: pp. 118TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A man self-administers aqueous epinephrine after experiencing a bee sting and developing angioedema and wheezing. What should the man do next? a. Obtain transport to an emergency department immediately. b. Repeat the epinephrine dose if needed and notify a physician of the episode. c. Resume normal activity if symptom free after 30 to 60 minutes. d. Take oral diphenhydramine and report any symptoms to a provider.

ANS: A The man has a history of anaphylaxis and experienced symptoms after contact with a trigger. The aqueous epinephrine should be used immediately but does not prevent the need for follow up in an emergency department for close observation, since continued reaction to the allergen can occur for 6 to 8 hours. The epinephrine dose may be given if needed before emergency personnel arrive, but a second dose is not enough to prevent ongoing reaction to the allergen.

Which symptom in a patient diagnosed with asthma indicates severe bronchospasm? a. Breathlessness with minimal activity or eating b. Pausing to breathe while attempting to talk c. Repetitive, spasmodic coughing at night d. Wheezing after exposure to a trigger

ANS: B Inability to speak a full sentence without pausing to breathe indicates severe bronchospasm. Breathlessness, repetitive and spasmodic coughing, and wheezing are all common signs of bronchospasm and do not necessarily indicate severe bronchospasm.

A patient who uses an inhaled glucocorticoid for chronic asthma calls the nurse to report hoarseness. What will the nurse do? a. Ask whether the patient is rinsing the mouth after each dose. b. Request an order for an antifungal medication. c. Suggest that the patient be tested for a bronchial infection. d. Tell the patient to discontinue use of the glucocorticoid.

ANS: A The most common side effects of inhaled glucocorticoids are oropharyngeal candidiasis and dysphonia. To minimize these, patients should be advised to gargle after each administration. Antifungal medications are used after a fungal infection has been diagnosed. Hoarseness is not a sign of a bronchial infection. There is no need to discontinue the glucocorticoid.DIF: Cognitive Level: ApplicationREF: p. 678TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient who has been newly diagnosed with asthma is referred to an asthma clinic. The patient reports daily symptoms requiring short-acting beta2-agonist treatments for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient's forced expiratory volume in 1 second (FEV1) is 75% of the predicted values. The nurse will expect this patient to be started on which regimen? a. Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed b. Daily low-dose inhaled glucocorticoid and a SABA as needed c. Daily medium-dose inhaled glucocorticoid/LABA combination d. No daily medications; just a SABA as needed

ANS: A This patient has moderate persistent asthma, which requires step 3 management for initial treatment. Step 3 includes daily inhalation of a low-dose glucocorticoid/LABA combination supplemented with a SABA as needed. A daily low-dose glucocorticoid with an as-needed SABA is used for step 2 management. A daily medium-dose glucocorticoid/LABA is used for step 4 management. Patients requiring step 1 management do not need daily medications.DIF: Cognitive Level: ApplicationREF: p. 689TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient with no known drug allergies is receiving amoxicillin [Amoxil] PO twice daily. Twenty minutes after being given a dose, the patient complains of shortness of breath. The patient's blood pressure is 100/58 mm Hg. What will the nurse do? a. Contact the provider and prepare to administer epinephrine. b. Notify the provider if the patient develops a rash. c. Request an order for a skin test to evaluate possible PCN allergy. d. Withhold the next dose until symptoms subside.

ANS: A This patient is showing signs of an immediate penicillin allergy, that is, one that occurs within 2 to 30 minutes after administration of the drug. The patient is showing signs of anaphylaxis, which include laryngeal edema, bronchoconstriction, and hypotension; these must be treated with epinephrine. This is an emergency, and the provider must be notified immediately, not when other symptoms develop. It is not necessary to order skin testing. The patient must be treated immediately, and subsequent doses should not be given.DIF: Cognitive Level: ApplicationREF: p. 788TOP: Nursing Process: Diagnosis MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient who has just learned she is pregnant has stopped using a prescription medication that she takes for asthma because she does not want to harm her baby. What will the nurse tell her? a. That asthma medications will not affect the fetus b. That her baby's health is dependent on hers c. To avoid taking medications during her pregnancy d. To resume the medication in her second trimester

ANS: B Asthmatic women who fail to take medication have a doubled risk of stillbirth; therefore, the nurse should encourage the patient to use her medications. Because the health of the fetus depends on the health of the mother, all drugs must be considered in light of the benefits of treatment versus the risks to the fetus. Asthma medications may have effects on the fetus, but the risk of stillbirth presents a greater risk. In this case, the patient needs to take the medication to treat her asthma and not wait until the second trimester.DIF: Cognitive Level: ApplicationREF: p. 61TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation

A patient presents with a cough and fever. The provider auscultates rales in both lungs that do not clear with cough. The patient reports having a headache and sore throat prior to the onset of coughing. A chest radiograph shows patchy, nonhomogeneous infiltrates. Based on these findings, which organism is the most likely cause of this patient's pneumonia? a. A virus b. Mycoplasma c. S. pneumoniae d. Tuberculosis

ANS: B Atypical pneumonias, such as those caused by mycoplasma, often present with headache and sore throat and will have larger areas of infiltrate on chest radiograph. Viral pneumonias show more diffuse radiographic findings. S. pneumonia will have high fever and cough and distinct areas of infiltration.

A young adult patient develops a cough persisting longer than 2 months. The provider prescribes pulmonary function tests and a chest radiograph, which are normal. The patient denies abdominal complaints. There are no signs of rhinitis or sinusitis and the patient does not take any medications. What will the provider evaluate next to help determine the cause of this cough? a. 24-hour esophageal pH monitoring b. Methacholine challenge test c. Sputum culture d. Tuberculosis testing

ANS: B Chronic cough without other symptoms may indicate asthma. If PFTs are normal, a methacholine challenge test may be performed. 24-hour esophageal pH monitoring is sometimes performed to evaluate for GERD, but this patient does not have abdominal symptoms and this test is usually not performed because it is inconvenient. Sputum culture is not indicated. TB is less likely.

An older adult patient diagnosed with chronic obstructive lung disease (COPD) is experiencing dyspnea and has an oxygen saturation of 89% on room air. The patient has no history of pulmonary hypertension or congestive heart failure. What will the provider order to help manage this patient's dyspnea? a. Anxiolytic drugs b. Breathing exercises c. Opioid medications d. Supplemental oxygen

ANS: B Formal pulmonary rehabilitation programs, including breathing exercises, are used to manage long-term disease such as COPD. Anxiolytics and opioids must be used cautiously because of respiratory depression side effects. Medicare does not approve oxygen supplementation unless saturations are less than 88% on room air or for patients who have pulmonary hypertension or CHF who have saturations <89%.

A nurse is teaching a group of nursing students about influenza prevention. Which statement by a student indicates understanding of the teaching? a. "I may develop a mild case of influenza if I receive the vaccine by injection." b. "I should receive the vaccine every year in October or November." c. "If I have a cold I should postpone getting the vaccine." d. "The antiviral medications are as effective as the flu vaccine for preventing the flu."

ANS: B Influenza vaccine should be given every year in October or November. The vaccine will not cause influenza. Minor illnesses, such as a cold, are not a contraindication for receiving the vaccine. Antiviral medications are not as effective as the flu vaccine in preventing influenza.DIF: Cognitive Level: ApplicationREF: p. 883TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A young adult woman will begin using an inhaled glucocorticoid to treat asthma. The nurse will teach this patient about the importance of which action? a. Lowering her calcium intake and increasing her vitamin D intake b. Participating in weight-bearing exercises on a regular basis c. Taking oral glucocorticoids during times of acute stress d. Using two reliable forms of birth control to prevent pregnancy

ANS: B Like oral glucocorticoids, inhaled glucocorticoids can promote bone loss in premenopausal women. Patients should be encouraged to participate in weight-bearing exercises to help minimize this side effect. Patients should increase both their calcium and vitamin D intakes. Patients taking oral glucocorticoids need increased steroids in times of stress. It is not necessary to use two reliable forms of birth control.DIF: Cognitive Level: ApplicationREF: p. 678TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient has a positive test for influenza type A and tells the nurse that symptoms began 5 days before being tested. The prescriber has ordered oseltamivir [Tamiflu]. The nurse will tell the patient that oseltamivir: a. may decrease symptom duration by 2 or 3 days. b. may not be effective because of the delay in starting treatment. c. may reduce the severity but not the duration of symptoms. d. will alleviate symptoms within 24 hours of the start of therapy.

ANS: B Oseltamivir is most effective when begun within 2 days after symptom onset. When started within 12 hours ofsymptomonset, it maydecrease duration ofsymptoms by 2 to 3 days. The drug reduces both symptom severity and symptom duration when used in a timely fashion. It does not rapidly alleviate symptoms.DIF: Cognitive Level: ApplicationREF: p. 884TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient is seen in clinic for an asthma exacerbation. The provider administers three nebulizer treatments with little improvement, noting a pulse oximetry reading of 90% with 2 L of oxygen. A peak flow assessment is 70%. What is the next step in treating this patient? a. Administer three more nebulizer treatments and reassess. b. Admit to the hospital with specialist consultation. c. Give epinephrine injections and monitor response. d. Prescribe an oral corticosteroid medication.

ANS: B Patients having an asthma exacerbation should be referred if they fail to improve after three nebulizer treatments or three epinephrine injections, have a peak flow less than 70% and a pulse oximetry reading less than 90% on room air. Giving more nebulizer treatments or administering epinephrine is not indicated. The patient will most likely be given IV corticosteroids; oral corticosteroids would be given if the patient is managed as an outpatient.

An older adult patient with chronic obstructive pulmonary disease (COPD) develops bronchitis. The patient has a temperature of 39.5° C. The nurse will expect the provider to: a. obtain a sputum culture and wait for the results before prescribing an antibiotic. b. order empiric antibiotics while waiting for sputum culture results. c. treat symptomatically, because antibiotics are usually ineffective against bronchitis. d. treat the patient with more than one antibiotic without obtaining cultures.

ANS: B Patients with severe infections should be treated while culture results are pending. If a patient has a severe infection or is at risk of serious sequelae if treatment is not begun immediately, it is not correct to wait for culture results before beginning treatment. Until a bacterial infection is ruled out, treating symptomatically is not indicated. Treating without obtaining cultures is not recommended.DIF: Cognitive Level: ApplicationREF: p. 774TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient taking three medications for hypertension is diagnosed with COPD. Which action should be taken prior to prescribing medications to treat COPD? a. Obtain baseline laboratory values. b. Obtain a complete medication history. c. Assess liver enzyme levels. d. Determine if patient has insurance coverage.

ANS: B Prior to adding medications to the treatment regimen, it is essential to assess for any potential drug-drug interactions through a complete medical history. Baseline laboratory values are not necessary for COPD treatment. Liver enzyme levels may give insight into the possibility of altered metabolism but would not be the first action. The presence of insurance coverage would affect the patient's access to treatment but may not affect the type of medication prescribed.DIF: Cognitive Level: ApplicationREF: p. 6TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A patient reporting dyspnea and chest pain along with occasional chills and night sweats has a chest radiograph that shows bilateral hilar lymphadenopathy (BHL) and pulmonary infiltrates. The provider suspects which classification of sarcoidosis? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

ANS: B Stage 1 sarcoidosis is classified based on bilateral hilar lymphadenopathy (BHL) only. Stage 2 presents with BHL and pulmonary infiltrates, stage 3 with pulmonary infiltrates without BHL, and stage 4 with pulmonary fibrosis.

A healthcare professional is educating a patient about asthma. The professional states that good control is necessary due to which pathophysiologic process? a. Norepinephrine causes bronchial smooth muscle contraction and mucus secretion but it also causes high blood pressure. b. Uncontrolled inflammation leads to increased bronchial hyperresponsiveness and eventual scarring. c. The release of epinephrine leads to development of cardiac dysrhythmias. d. Immunoglobulin G causes smooth muscle contraction which will eventually weaken the respiratory muscles.

ANS: B The late asthmatic response begins 4 to 8 hours after the early response when the release of toxic neuropeptides contributes to increased bronchial hyperresponsiveness. Untreated inflammation leads to increased scarring and remodeling of pulmonary tissue, so good control of asthma is necessary to prevent that complication. Poor asthma control does not specifically lead to hypertension or dysrhythmias, nor will it permanently weaken respiratory muscles.

A child with no previous history of asthma is brought to the emergency department with wheezing, stridor, and shortness of breath. When the child is started on oxygen and given a nebulized bronchodilator treatment, the treatment team notes a wheal and flare rash on the child's trunk. What medication will be given immediately? a. Inhaled racemic epinephrine b. Intramuscular epinephrine c. Intravenous diphenhydramine d. Intravenous ranitidine

ANS: B The patient has signs of anaphylaxis and should be given IM or SC epinephrine immediately as first-line therapy, with this repeated every 5 to 20 minutes as needed to prevent cardiovascular shock. Inhaled epinephrine is used for acute upper airway bronchospasm. Diphenhydramine and ranitidine are given as second-line treatment after epinephrine is administered or for mild, non-life-threatening allergic reactions.

A patient reports shortness of breath with activity and exhibits increased work of breathing with prolonged expirations. Which diagnostic test will the provider order to confirm a diagnosis in this patient? a. Arterial blood gases b. Blood cultures c. Spirometry d. Ventilation/perfusion scan

ANS: C The patient has signs of either asthma or COPD. Spirometry is essential to both the diagnosis and management of these diseases. ABGs are useful when evaluating the severity of exacerbations but are not specific to these diseases. Blood cultures are drawn if pneumonia is suspected. A ventilation/perfusion scan is performed to evaluate for pulmonary thromboembolic disease.

A patient is using a metered-dose inhaler containing albuterol for asthma. The medication label instructs the patient to administer "two puffs every 4 hours as needed for coughing or wheezing." The patient reports feeling jittery sometimes when taking the medication, and she doesn't feel that the medication is always effective. Which action is most appropriate? a. Asking the patient to demonstrate use of the inhaler b. Assessing the patient's exposure to tobacco smoke c. Auscultating lung sounds and obtaining vital signs d. Suggesting that the patient use one puff to reduce side effects

ANS: C Asking the patient to demonstrate inhaler use helps to evaluate the patient's ability to administer the medication properly and is part of the nurse's evaluation, but is not a priority intervention based on the patient's current report. Assessing tobacco smoke exposure helps the nurse determine whether nondrug therapies, such as smoke avoidance, can be used as an adjunct to drug therapy, but does not relate to the patient's current problem. Performing a physical assessment helps the nurse evaluate the patient's response to the medication and identify the presence of other side effects.DIF: Cognitive Level: ApplicationREF: p. 13TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and ParenteralTherapies

A student asks the healthcare professional why researchers are trying to link specific genes to specific asthma phenotypes. What response by the professional is best? a. Some types of asthma are easier to treat than others. b. Some people could use cheaper medications. c. It can lead to personalized approaches to treatment. d. More and more asthma phenotypes are being recognized.

ANS: C Linking specific genes to specific asthma phenotypes is leading to targeted therapies and personalized approaches to asthma treatment. It may be true that some types are easier to treat or that some people could use different, less expensive medications, but those responses are too narrow in focus to be the best answer. Several phenotypes of asthma have already been recognized.

A patient with asthma is admitted to an emergency department with a respiratory rate of 22 breaths/minute, a prolonged expiratory phase, tight wheezes, and an oxygen saturation of 90% on room air. The patient reports using fluticasone [Flovent HFA] 110 μg twice daily and has used 2 puffs of albuterol[Proventil HFA], 90 mcg/puff, every 4 hours for 2 days. The nurse will expect to administer which drug? a. Four puffs of albuterol, oxygen, and intravenous theophylline b. Intramuscular glucocorticoids and salmeterol by metered-dose inhaler c. Intravenous glucocorticoids, nebulized albuterol and ipratropium, and oxygen d. Intravenous theophylline, oxygen, and fluticasone (Flovent HFA) 220 mcg

ANS: C Patients using inhaled glucocorticoids should be given IV or oral glucocorticoids for acute exacerbations. During asthma flares, nebulized albuterol with ipratropium may be better tolerated and more effective. Oxygen is indicated, because oxygen saturations are low despite the increased work of breathing. Increasing the dose of albuterol and giving theophylline are not indicated. Salmeterol is a long-term beta agonist and is not useful in an acute attack.DIF: Cognitive Level: AnalysisREF: p. 689TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient diagnosed with asthma has been prescribed three bronchodilator treatments but continues to experience wheezing and shortness of breath. The health care provider caring for the patient notes an oxygen saturation of 90% on room air. What action is indicated? a. Administer oxygen and continue to monitor the patient. b. Contact the respiratory therapist to administer another treatment. c. Notify the patient's physician immediately. d. Reassure the patient that the treatments will take effect soon.

ANS: C Patients with bronchospasm who have oxygen saturations less than 92% on room air and who fail to improve with nebulizer treatment given three times, need physician consultation. While oxygen administration and further nebulizer treatments may be indicated, it is incorrect to continue to monitor the patient without notifying the physician.

Which diagnostic test is most useful when monitoring the progression of sarcoidosis over a long period of time? a. Chest radiographs b. Erythrocyte sedimentation rate (ESR) c. Pulmonary function test (PFT) d. Radionucleotide scanning

ANS: C Pulmonary function tests may be normal or may demonstrate a restrictive pattern and may be of most value in monitoring the course of the disease in individual cases. Chest radiographs may help with staging the disease initially. The ESR may be elevated with sarcoidosis but is a non-specific finding. Radionucleotide scanning is non-specific, although it can be used to locate the presence of pulmonary lesions.

A young, previously healthy adult clinic patient reports symptoms of pneumonia including high fever and cough. Auscultation reveals rales in the left lower lobe. A chest radiograph is normal. The patient is unable to expectorate sputum. Which treatment is recommended for this patient? a. A B-lactam antibiotic plus a fluoroquinolone b. A respiratory fluoroquinolone antibiotic c. Empirical treatment with a macrolide antibiotic d. Hospitalization for intravenous antibiotics

ANS: C This patient likely has community-acquired pneumonia. The patient has typical symptoms and, even though the chest radiograph is normal, will require outpatient treatment. For community-acquired pneumonia in a previously healthy individual, treatment with a macrolide antibiotic is the recommended first-line therapy. B-lactam plus fluoroquinolone therapy is used for patients in the ICU. Respiratory fluoroquinolones are used for patients with underlying disorders who develop pneumonia. Hospitalization is not necessary.

A patient was initially treated as an outpatient for pneumonia and then after 2 weeks was hospitalized after no improvement was evident. The patient continues to show no improvement after several antibiotic regimens have been attempted. What is the next step in managing this patient? a. Administration of the pneumonia vaccine b. Increasing the dose of the antibiotics c. Open lung biopsy d. Performing diagnostic bronchoscopy

ANS: D Patients who do not respond to antibiotic therapy may have opportunistic fungal or other infections, bronchogenic carcinoma, or other diseases. Bronchoscopy can exclude or confirm these. The pneumonia vaccine is preventative for pneumococcal causes and will not help this patient. Increasing the dose of the antibiotics is not recommended. Open lung biopsy may be performed if a bronchoscopy is inconclusive.

A patient comes to the Emergency Department with inspiratory and expiratory wheezing, dyspnea, nonproductive cough, and tachypnea. What treatment does the healthcare professional anticipate for this patient as the priority? a. Sputum culture b. History of illness exposure c. Antibiotics d. Inhaled bronchodilator

ANS: D Asthma is characterized by expiratory wheezing, dyspnea, non-productive coughing, prolonged expiration, tachycardia, and tachypnea. Severe attacks involve the use of accessory muscles of respiration, and wheezing is heard during both inspiration and expiration. The treatment consists of inhaled Beta-agonist bronchodilators, oxygen if needed, and corticosteroids. After the patient has been stabilized, the healthcare professional attempts to determine the cause of the attack, which would include a possible sputum culture and getting a history of any recent exposures to illness. Antibiotics will be given for a bacterial infection, such as pneumonia or pharyngitis, that led to the attack.

A patient diagnosed with stage 1 sarcoidosis is prescribed a nonsteroidal anti-inflammatory medication to treat joint discomfort has now developed mild dyspnea and cough. Which medication will be added to assist in treating this new symptom? a. A beta-adrenergic medication b. An antimalarial agent c. An immunosuppressant drug d. An oral corticosteroid

ANS: D Corticosteroids are begun when pulmonary symptoms develop. Beta-adrenergics are not used. Antimalarial agents are used to treat chronic skin lesions. Immunosuppressants are used when corticosteroids are no longer effective or when the disease progresses.

The parent of a 4-month-old infant who has had an episode of bronchiolitis asks the provider if the infant may have an influenza vaccine. What will the provider tell this parent? a. The infant should be given prophylactic antiviral medications. b. The infant should have an influenza vaccine now with a booster in 1 month. c. The infant should have the live attenuated influenza vaccine (LAIV). d. The infant should not but family and all close contacts should be vaccinated.

ANS: D Infants are not given influenza vaccine until age 6 months. To protect infants younger than 6 months, it is important for other family members and close contacts to be vaccinated. LAIV is approved for use in children over age 2 years. Antiviral prophylaxis is not recommended.

A patient with stable COPD receives prescriptions for an inhaled glucocorticoid and an inhaled beta2-adrenergic agonist. Which statement by the patient indicates understanding of this medication regimen? a. "I should use the glucocorticoid as needed when symptoms flare." b. "I will need to use the beta2-adrenergic agonist drug daily." c. "The beta2-adrenergic agonist suppresses the synthesis of inflammatory mediators." d. "The glucocorticoid is used as prophylaxis to prevent exacerbations."

ANS: D Inhaled glucocorticoids are used daily to prevent acute attacks. They are not used PRN. The beta2- adrenergic agonist drugs should not be used daily; they are used to treat symptoms as needed. They do not suppress mediators of inflammation.DIF: Cognitive Level: ApplicationREF: p. 690TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient with persistent, frequent asthma exacerbations asks a nurse about a long-acting beta2- agonist medication. What will the nurse tell this patient? a. LABAs are safer than short-acting beta2 agonists. b. LABAs can be used on an as-needed basis to treat symptoms. c. LABAs reduce the risk of asthma-related deaths. d. LABAs should be combined with an inhaled glucocorticoid.

ANS: D LABAs can increase the risk of asthma-related deaths when used improperly; this risk is minimized when LABAs are combined with an inhaled glucocorticoid. LABAs are not safer than SABAs, and they are not used PRN. LABAs increase the risk of asthma-related deaths.DIF: Cognitive Level: ApplicationREF: p. 682TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Which medication should be used for asthma patients as part of step 1 management? a. Combination inhaled glucocorticoids/long-acting beta2 agonists b. Inhaled low-dose glucocorticoids c. Long-acting beta2 agonists d. Short-acting beta2 agonists

ANS: D Patients needing step 1 management have intermittent, mild symptoms and can be managed with a SABA as needed. Combination inhaled glucocorticoids/LABAs are used for step 3 management. Inhaled low-dose glucocorticoids are used for step 2 management. LABAs, along with inhaled glucocorticoids, are used for step 3 management.DIF: Cognitive Level: AnalysisREF: p. 689TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A 65-year-old patient who has not had an influenza vaccine is exposed to influenza and comes to the clinic the following day with a fever and watery, red eyes. What will the provider do initially? a. Administer LAIV influenza vaccine b. Begin treatment with an antiviral medication c. Observe for improvement or worsening for 24 hours d. Perform a nasal swab for RT-PCR assay

ANS: D Samples to isolate the virus should be collected within 12 to 36 hours of onset of illness and this should be performed to confirm the disease. Administration of the LAIV influenza vaccine will not prevent symptoms in this patient, is not recommended in persons over 59 years of age, and is contraindicated when also giving antiviral medications. Antiviral drugs should be started within 48 hours of onset of illness and may be started empirically while waiting on cultures because this patient is higher risk than younger patients. Because identification of the virus and effectiveness of treatment are time-limited, it is not correct to watch and wait for symptoms to worsen.

An adult develops chronic cough with episodes of wheezing and shortness of breath. The provider performs chest radiography and other tests and rules out infection, upper respiratory, and gastroesophageal causes. Which test will the provider order initially to evaluate the possibility of asthma as the cause of these symptoms? a. Allergy testing b. Methacholine challenge test c. Peak expiratory flow rate (PEFR) d. Spirometry

ANS: D Spirometry is recommended at the time of initial assessment to confirm the diagnosis of asthma. Allergy testing is performed only if allergies are a possible trigger. The methacholine challenge test is performed if spirometry is inconclusive. PEFR is generally used to monitor asthma symptoms.

Which test is the most diagnostic for chronic obstructive pulmonary disease (COPD)? a. COPD Assessment Test b. Forced expiratory time maneuver c. Lung radiograph d. Spirometry for FVC and FEV1

ANS: D Spirometry testing is the gold standard for diagnosis and assessment of COPD because it is reproducible and objective. The forced expiratory time maneuver is easy to perform in a clinic setting and is a good screening to indicate a need for confirmatory spirometry. Lung radiographs are non-specific but may indicate hyperexpansion of lungs. The COPD assessment test helps measure health status impairment in persons already diagnosed with COPD.

A previously healthy patient develops influenza which is confirmed by RT-PCR testing and begins taking an antiviral medication. The next day, the patient reports increased fever and cough without respiratory distress. The patient's lungs are clear and oxygen saturations are 97% on room air. What will the provider recommend? a. Admission to the hospital for treatment of complications b. Empirical antibiotics to treat a possible secondary infection c. Referral to a specialist for evaluation and treatment d. Symptomatic treatment with close follow-up in clinic

ANS: D This patient does not have risk factors for serious complications and may be managed as an outpatient. Symptoms should begin to gradually improve a few days after the onset of symptoms. Because this patient is stable, watchful waiting with symptomatic care and close follow up is acceptable. It is not necessary to admit to the hospital, refer to a specialist, or begin antibiotic therapy currently.

A patient who has excessive daytime sleepiness tells the practitioner that he goes to bed and gets up at the same time each day but still wakes up tired. The spouse reports that the patient snores so much she has had to move to another bedroom. The patient is otherwise healthy and does not take any medications or drink alcohol. Which diagnostic test may be performed for this patient? a. Full overnight polysomnography (PSG) b. Multiple sleep latency test (MSLT) c. Overnight pulse oximetry d. Unattended out of center sleep testing (OCST)

ANS: D This patient has a high probability of OSA without significant comorbidities or use of medications that may cause central sleep apnea, so this test, which has more limited measures than a full PSG, may be performed. Full overnight PSG is used when the cause of sleep apnea is less certain to help determine whether there is a central cause. The multiple sleep latency test is used to test EDS symptoms. Overnight pulse oximetry is not sufficiently sensitive to be a reliable screening for sleep apnea.

A patient with COPD is prescribed tiotropium [Spiriva]. After the initial dose, the patient reports only mild relief within 30 minutes. What will the nurse tell the patient? a. "You may have another dose in 4 hours." b. "You may need to take two inhalations instead of one." c. "You should have peak effects in about 6 hours." d. "You should see improved effects within the next week."

ANS: D Tiotropium shows therapeutic effects in about 30 minutes, with improved bronchodilation occurring with subsequent doses, up to 8 days. The medication is given once daily, with inhalation of one capsule. Peak effects occur in 3 hours.DIF: Cognitive Level: ApplicationREF: p. 686TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A patient with asthma comes to a clinic for treatment of an asthma exacerbation. Thepatient's medication history lists an inhaled glucocorticoid, montelukast [Singulair], and a SABA as needed via MDI. The nurse assesses the patient and notes a respiratory rate of 18 breaths/minute, a heart rate of 96 beats/minute, and an oxygen saturation of 95%. The nurse auscultates mild expiratory wheezes and equal breath sounds bilaterally. What will the nurse do? a. Contact the provider to request a systemic glucocorticoid. b. Contact the provider to suggest using a long-acting beta2 agonist. c. Evaluate the need for teaching about MDI use. d. Question the patient about how much albuterol has been used.

ANS: D To determine the next course of action, it is important to assess the drugs given before these symptoms were observed. Patients who continue to wheeze after using a SABA need systemic glucocorticoids and nebulized albuterol. If a SABA has not been used, that will be the first intervention. LABAs are not used for exacerbations. If a patient reports using a SABA without good results, evaluating the MDI technique may be warranted.DIF: Cognitive Level: ApplicationREF: p. 689TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential

A patient with asthma will be using a metered-dose inhaler (MDI) for delivery of an inhaled medication. The provider has ordered 2 puffs to be given twice daily. It is important for the nurse to teach this patient that: a. the patient should inhale suddenly to receive the maximum dose. b. the patient should activate the device and then inhale. c. the patient should store the MDI in the refrigerator between doses. d. the patient should wait 1 minute between puffs.

ANS: D When two puffs are needed, an interval of at least 1 minute should separate the first puff from the second. Sudden inhalation can cause bronchospasm. The patient should begin inhaling and then activate the device. There is no need to store the drug in the refrigerator.DIF: Cognitive Level: ApplicationREF: p. 683TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies