CH 29 obstructive pulmonary disease

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.Pulse oximetry reading of 91% b.Absence of wheezes or crackles c.Decreased use of accessory muscles d.Respiratory rate of 22 breaths/minute

ANS: A 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.

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. The nurse will plan to a.carry out the procedure 3 hours after the patient eats. b.maintain the patient in the lateral position for 20 minutes. c.perform percussion before assisting the patient to the drainage position. d.give the ordered albuterol (Proventil) after the patient has received the therapy.

ANS: A 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. Bronchodilators are administered before chest physiotherapy.

When the nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack, which finding is the best indicator that the therapy has been effective? a.No wheezes are audible. b.Oxygen 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 oxygen saturation >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.

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

ANS: A A respiratory rate of 38 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 tachypneic patient.

A patient with chronic bronchitis who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that a. one drug decreases inflammation, and the other is a bronchodilator. b. Advair is a combination of long-acting and slow-acting bronchodilators. c. the combination of two drugs works more quickly in an acute asthma attack. d. the two drugs work together to block the effects of histamine on the bronchioles.

ANS: A Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not used during an acute attack because the medications do not work rapidly.

The nurse has completed patient teaching about the administration of salmeterol (Serevent) using a metered-dose inhaler (MDI). Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the MDI. b. The patient coughs vigorously after using the inhaler. c. The patient floats the MDI in water to see if it is empty. d. The patient activates the inhaler at the onset of expiration.

ANS: A Spacers can improve the delivery of medication to the lower airways. The other patient actions indicate a need for further teaching.

A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, it is most important that the nurse a.keep the air entrainment ports clean and unobstructed. b.give a high enough flow rate to keep the bag from collapsing. c.use an appropriate adaptor to ensure adequate oxygen delivery. d.drain moisture condensation from the oxygen tubing every hour.

ANS: A The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or non-rebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? a. 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg b. 32-year-old with ABG results: pH 7.50, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. 40-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. 64-year-old with ABG results: 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. The other patients also should be assessed as quickly as possible, but do not require interventions as quickly as the 20-year-old.

Which action should the nurse anticipate taking first when a patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing? a. Assist with endotracheal intubation. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (SoluMedrol).

ANS: A The patients assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation. 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.

A 32-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of emphysema. The nurse will anticipate teaching the patient about a.a1-antitrypsin testing. b.use of the nicotine patch. c.continuous pulse oximetry. d.effects of leukotriene modifiers.

ANS: A When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in a1-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 emphysema.

Which 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. Respiratory rate 22 breaths/minute d. Peak flow reading 75% of normal

ANS: B Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction; immediate intervention is needed. The other information also should be reported, but do not indicate possibly life-threatening complications of the omalizumab therapy.

After the nurse has completed diet teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a body mass index (BMI) of 20, which patient statement indicates that the teaching has been effective? a. I will drink lots of fluids with my meals. b. I will 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 or poultry.

ANS: B High-calorie foods like 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.

A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the patient to improve gas exchange? a.Resting in bed with the head elevated to 45 to 60 degrees b.Sitting up at the bedside in a chair and leaning slightly forward c.Resting in bed in a high-Fowlers position with the knees flexed d.In the Trendelenburg position with several 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 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 patients ability to ventilate well.

Which diagnostic test will the nurse plan to discuss with a 54-year-old patient with progressively increasing dyspnea who is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD)? a.Eosinophil count b.Pulmonary function testing c.Immunoglobin E (IgE) levels d.Radioallergosorbent test (RAST)

ANS: B Pulmonary function testing will help establish the COPD diagnosis. The other tests would be used to test for an allergic component for asthma, but will not be used in the diagnosis of COPD.

When a hospitalized patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen, the best action by the nurse is to a.minimize oxygen use to avoid oxygen dependency. b.maintain the pulse oximetry level at 90% or greater. c.administer oxygen according to the patients level of dyspnea. d.avoid administration of oxygen at a rate of more than 2 L/min.

ANS: B The best way to determine the appropriate oxygen flow rate is by monitoring the patients oxygenation either by arterial blood gases (ABGs) or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patients perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level.

When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe chronic obstructive pulmonary disease (COPD), the nurse should teach the patient that an appropriate exercise goal is to a.walk until pulse rate exceeds 130. b.walk for a total of 20 minutes daily. c.exercise until shortness of breath occurs. d.limit exercise to activities of daily living (ADLs).

ANS: B The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patients exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150).

After the nurse has finished teaching a patient about pursed lip breathing, which patient action indicates that more 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 patients 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.

A patient with asthma who has a baseline peak flow reading of 600 mL calls the nurse, stating that the current peak flow is 420 mL. 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 (Proventil). 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 patients peak flow is 70% of normal, indicating a need for immediate use of short-acting b2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens also is appropriate, but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed.

When teaching the patient with chronic obstructive pulmonary disease (COPD) about exercise, which information should the nurse include? a. Stop exercising if you start to feel short of breath. b. Use the bronchodilator before you start to exercise. c. Breathe in and out through the mouth while you exercise. d. Upper body exercise should be avoided to prevent dyspnea.

ANS: B 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.

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

ANS: C 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 patients problem of thick mucous secretions.

To evaluate the effectiveness of therapy for a patient with cor pulmonale, the nurse will monitor the patient for a.elevated temperature. b.clubbing of the fingers. c.jugular vein distention. d.complaints of chest pain.

ANS: C Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distention. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease (COPD) but are not indicators of cor pulmonale.

Which topic will the nurse include in medication teaching for a patient with newly-diagnosed persistent asthma? a. Use of long-acting b-adrenergic medications b. Side effects of sustained-release theophylline c. Self-administration of inhaled corticosteroids d. Complications associated with oxygen 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.

Which action by a patient who has asthma indicates a good understanding of the nurses teaching about peak flow meter use? a.The patient records an average of three peak flow readings every day. b.The patient inhales rapidly through the peak flow meter mouthpiece. c.The patient uses the albuterol (Proventil) metered-dose inhaler (MDI) for peak flows in the yellow zone. d.The patient calls the health care provider when the peak flow is in the green zone.

ANS: C Readings in the yellow zone indicate a decrease in peak flow; the patient should use short-acting b2-adrenergic (SABA) medications. The best of three peak flow readings should be recorded. 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.

A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take? a.teach the patient about the use of oral corticosteroids. b.Administer a bronchodilator and recheck the peak flow. c.Instruct the patient to continue to use current medications. d.Evaluate whether the peak flow meter is being used correctly.

ANS: C The patients peak flow readings indicate good asthma control, and no changes are needed. The other actions would be used for patients in the yellow or red zones for peak flow.

When caring for a patient with a history of asthma, which assessment finding should the nurse communicate immediately to the health care provider? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/minute c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 mL/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.

When the nurse takes an admission history for 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 a history of pneumonia 2 years ago. b. The patient has chronic inflammatory bowel disease. c. the patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

ANS: C b-blockers such as propranolol can cause bronchospasm in some patients. The other information will be documented in the health history but does not indicate a need for a change in therapy.

When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis? a.The patient tells the nurse about a family history of bronchitis. b.The patients history indicates a 40 pack-year cigarette history. c.The patient denies having any respiratory problems until the last 6 months. d.The patient complains about a productive cough every winter for 3 months.

ANS: D 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 familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.

When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to a.avoid eating or drinking for several hours before the testing. b.use rescue medications immediately before the tests are done. c.take oral corticosteroids at least 2 hours before the examination. d.withhold bronchodilators for 6 to 12 hours before the examination.

ANS: D Bronchodilators are held before pulmonary function testing 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 also should be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

Which information about a newly admitted patient with chronic obstructive pulmonary disease (COPD) indicates that the nurse should consult with the health care provider before administering the prescribed theophylline? a.The patient has had a recent 10-pound weight gain. b.The patient has a cough productive of green mucus. c.The patient denies any shortness of breath at present. d.The patient takes cimetidine (Tagamet) 150 mg daily.

ANS: D Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not impact on whether the theophylline should be administered or not.

Which information given by an asthmatic patient while the nurse is doing the admission assessment is most indicative of a need for a change in therapy? a. The patient uses cromolyn (Intal) before any aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patients heart rate increases after using the albuterol (Proventil) inhaler. d. The patients only medications are albuterol (Proventil) and salmeterol (Serevent).

ANS: D Long-acting b2-agonists should be used only in patients who also are using an inhaled cortico-steroid for long-term control. Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma

A patient with chronic bronchitis has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? a.Titrate oxygen to keep saturation at least 90%. b.Discuss a high-protein, high-calorie diet with the patient. c.Suggest the use of over-the-counter sedative medications. d.Teach the patient how to effectively use pursed lip breathing.

ANS: D Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

Which information will the nurse include in teaching a patient with chronic obstructive pulmonary disease (COPD) who has a new prescription for home oxygen therapy? a.Storage of oxygen tanks will require adequate space in the home. b.Travel opportunities will be limited because of the use of oxygen. c.Oxygen flow should be increased if the patient has more dyspnea. d.Oxygen use can improve the patients prognosis and quality of life.

ANS: D Research supports the use of home oxygen to improve quality of life and prognosis. Since increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible by using portable oxygen concentrators.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, I wish I were dead! I cannot do anything for myself anymore. Based on this information, which nursing diagnosis is most appropriate? a.Complicated grieving related to expectation of death b.Ineffective coping related to unknown outcome of illness c.Deficient knowledge related to lack of education about COPD d.Chronic low self-esteem related to increased physical dependence

ANS: D The patients statement about not being able to do anything for himself or herself supports this diagnosis. Although deficient knowledge, complicated grieving, and ineffective coping also may be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses.

Which information will the nurse include when teaching the patient with asthma about the prescribed medications? a.Utilize 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 b2-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.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurses first action should be to a. listen to the patients 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 patients 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 patients 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.

Which of these nursing actions included in the care plan for a patient with chronic obstructive pulmonary disease (COPD) should the nurse delegate to experienced nursing assistive personnel (NAP)? a. Obtain oxygen saturation using pulse oximetry. b. Monitor for increased oxygen need with exercise. c. Teach the patient about safe use of oxygen at home. d. Adjust oxygen to keep saturation in prescribed parameters.

ANS: A NAP can obtain oxygen saturation (after being trained and evaluated in the skill). The other actions require more education scope of practice and should be done by LPN/LVNs or by RNs.

The following medications are prescribed by the health care provider for a patient having an acute asthma attack. Which one will the nurse administer first? a. salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) b. albuterol (Ventolin) 2.5 mg per nebulizer c. triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI) d. methylprednisolone (Solu-Medrol) 60 mg IV

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.

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. An appropriate intervention for this problem is to a.increase the patients intake of fruits and fruit juices. b.have the patient exercise for 10 minutes before meals. c.assist the patient in choosing foods with a lot of texture. d.offer high calorie snacks between meals and at bedtime.

ANS: D 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 may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.