Chapter 28 - Obstructive Pulmonary Diseases

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which of the following patient vital signs? A) Pulse rate of 76 B) Respiratory rate of 18 C) Temperature of 98.4° F D) Oxygen saturation 96%

A

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for which of the following potential triggers (select all that apply)? A) Exercise B) Allergies C) Emotional stress D) Decreased humidity E) Upper respiratory infections

A,B,C,E

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

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

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

A. Arterial pH 7.26 The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.

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

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

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

ANS: A The patient's assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time. DIF: Cognitive Level: Apply (application) REF: 565 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a. Pain at injection site b. Flushing and dizziness c. Peak flow reading 75% of normal d. Respiratory rate 22 breaths/minute

ANS: B Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate intervention is needed. The other information should also be reported, but do not indicate possibly life-threatening complications of omalizumab therapy. DIF: Cognitive Level: Apply (application) REF: 572 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: B For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue. DIF: Cognitive Level: Apply (application) REF: 598 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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

ANS: B 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. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation. The mask is uncomfortable and can be removed when the patient eats. DIF: Cognitive Level: Apply (application) REF: 591 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: B The best way to determine the appropriate oxygen flow rate is by monitoring the patient's 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 no concern about oxygen dependency. The patient's perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level. DIF: Cognitive Level: Apply (application) REF: 589 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well. DIF: Cognitive Level: Apply (application) REF: 599 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symptoms now and use the bronchodilator. DIF: Cognitive Level: Apply (application) REF: 580 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: D Bronchodilators are administered before chest physiotherapy. Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is done while the patient is in the postural drainage position. DIF: Cognitive Level: Apply (application) REF: 594 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: D Long-acting β2-agonists should be used only in patients who also are using an inhaled corticosteroid for long-term control. Salmeterol should not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse, but is not unusual for a patient with asthma. DIF: Cognitive Level: Apply (application) REF: 572 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which of the following test results identifies that a patient with an asthma attack is responding to treatment? A) An increase in CO2 levels B) A decreased exhaled nitric oxide C) A decrease in white blood cell count D) An increase in serum bicarbonate levels

B

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

B

A patient requires oxygen administration in low concentrations of 24% at 1 L/min for a long duration. Which device is the most appropriate for this patient? A. Face mask B. Nasal cannula C. Partial and non-rebreather masks D. Tracheostomy collar

B A nasal cannula is the most commonly used device for a patient requiring low concentrations of oxygen of 24% at 1 L/min. It is safe and simple and allows freedom of movement. It can be used for a long time. Simple face masks can be used only for a short duration, especially during transportation. Partial and non-rebreather masks are useful for short-term therapy with high concentrations of oxygen. A tracheostomy collar is used to deliver high humidity and oxygen.

While teaching a 45-year-old patient with asthma about the appropriate use of a peak flow meter, the nurse instructs the patient to notify the health care provider immediately if which situation occurs? A. Wheezing is improved moderately with the use of a bronchodilator. B. Less than 50% of the patient's personal best is achieved. C. The short-acting bronchodilator is being used every three to four days. D. Peak flow measurements remain unchanged after exercise.

B Achieving less than 50% of the patient's personal best on the peak flow meter indicates a medical emergency related to poor gas exchange and air flow. The patient should notify the health care provider immediately. Wheezing should be improved with a bronchodilator. Short acting bronchodilators used every one to two days indicate the need for additional asthma treatment. Peak flow measurements should not decrease following exercise if asthma is well-controlled.

An asthmatic patient is in acute respiratory distress. The nurse auscultates the lungs and notes cessation of inspiratory wheezing. How does the nurse interpret this finding? A. The patient has developed a pneumothorax B. There is worsening airway inflammation and bronchoconstriction C. Airflow has now improved through the bronchioles D. A mucus plug has developed within a main stem bronchus

B When the patient in respiratory distress has inspiratory wheezing that then ceases, it is an indication of airway obstruction and requires emergency action to restore the airway.. A pneumothorax would be evidenced by absent breath sounds. Absence of wheezing does not correlate with improved airflow if the patient is also in current respiratory distress. A mucus plug would result in crackles in the lungs.

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

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

A nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD). The lab reports of the patient reveal a hemoglobin level of 20 g/dL. What could be the reason for the increased hemoglobin? A. The patient consumes iron-rich food. B. The production of red blood cells increases in response to hypoxia. C. The heart is functioning well in response to COPD treatments. D. The patient no longer has COPD.

B. The production of red blood cells increases in response to hypoxia. In COPD, there is chronic hypoxia. To compensate for it, the production of RBC increases, leading to polycythemia or increased hemoglobin levels. The patient cannot have a hemoglobin level of 20 g/dL by eating iron-rich food. Patients with COPD usually have compromised heart function. The patient does have COPD and polycythemia is a defense response of the body against hypoxemia.

The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent) after noting which of the following assessment findings? A) Decreased respiratory rate B) Increased respiratory rate C) Increased peak flow readings D) Decreased sputum production

C

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which of the following findings? A) Absence of dyspnea B) Improved mental status C) Effective and productive coughing D) PaO2 within normal range for the patient

C

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate which of the following is likely to be the next step in treatment? A) Intravenous fluids B) Biofeedback therapy C) Systemic corticosteroids D) Pulmonary function testing

C

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring which of the following patient parameters? A) Apical pulse B) Bowel sounds C) Intake and output D) Deep tendon reflexes

C

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

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

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

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

Before discharge, the nurse discusses activity levels with a 61-year-old patient with COPD and pneumonia. Which of the following exercise goals is most appropriate once the patient is fully recovered from this episode of illness? A) Slightly increase activity over the current level. B) Swim for 10 min/day, gradually increasing to 30 min/day. C) Limit exercise to activities of daily living to conserve energy. D) Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

D

Nursing assessment findings of jugular vein distention and pedal edema would be indicative of which of the following complications of emphysema? A) Acute respiratory failure B) Secondary respiratory infection C) Pulmonary edema caused by left-sided heart failure D) Fluid volume excess resulting from cor pulmonale

D

The nurse is assisting a patient to learn self-administration of beclomethasone two puffs inhalation every 6 hours. The nurse explains that the best way to prevent oral infection while taking this medication is to do which of the following as part of the self-administration techniques? A) Chew a hard candy before the first puff of medication. B) Rinse the mouth with water before each puff of medication. C) Ask for a breath mint following the second puff of medication. D) Rinse the mouth with water following the second puff of medication.

D

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

D

A patient with emphysema is receiving oxygen at 1 L/min by way of nasal cannula. The nurse understands that this prescription is appropriate because: A. The patient does not require more than 1 L of oxygen B. High concentrations of oxygen may rupture the alveoli C. Oxygen is the natural stimulus for breathing and not required D. High concentrations of oxygen eliminate the respiratory drive

D Patients with emphysema become accustomed to a high level of carbon dioxide and low level of oxygen. This situation reverses the natural breathing stimulus. A low oxygen level then becomes the stimulus for breathing, and too much oxygen will eliminate the stimulus to breathe. There is not enough information to determine that the patient does not need more than 1 L of oxygen. A high concentrations of oxygen does not rupture alveoli. In healthy individuals, increased carbon dioxide, not oxygen, is the stimulus for breathing.