E2 130 - IV
What would be appropriate goal for client with severe COPD ?
- **If the client has severe COPD, goals are then to preserve current pulmonary function and relieve symptoms as much as possible. Examples of these goals are - Maintain activity level of walking to the mailbox. - Continue with current level of mobility at home. - Relieve shortness of breath to a level as close as possible to tolerable , in which the activity level is at current and symptoms are relieved to tolerable or close to tolerable.
A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that BEST supports this diagnosis is that the clien
BEST: Of the data listed, wheezing, an adventitious lung sound, is the best datum that supports the diagnosis of ineffective airway clearance - An increased respiratory rate and a report of dyspnea are also defining characteristics (but NOT BEST) of this nursing diagnosis
The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is:
Decreased carbon dioxide elimination results in increased carbon dioxide tension (hypercapnia), which leads to respiratory acidosis and chronic respiratory failure.
A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client?
If the client has MILD COPD, goals are to increase exercise and prevent further loss of pulmonary function. -The client who increases his walking distance without shortness of breath meets these criteria.
A nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). What instructions should the nurse include in the teaching? Select all that apply
The client activates the MDI once and takes a slow, deep inhalation, not normal inhalations. The client then holds the breath for 10 seconds. The spacer may increase delivery of the MDI medication
A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is:
The initial symptom is usually chest pain of sudden onset that leads to feelings of chest pressure, dyspnea, and tachycardia. A cough may be present.
What are the primary causes for an acute exacerbation of COPD? Select all that apply
- Common causes of an acute exacerbation include tracheobronchial infection and air pollution. However, the cause of approximately one third of severe exacerbations cannot be identified. - Winter is worse for COPD when viral and bacterial infections are more prevalent.
A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is
- Have you tried to quit smoking before - the nurse needs to assess the client's statement further. Assessment data include information about previous attempts to quit smoking
Which measure may increase complications for a client with COPD?
Administering too much oxygen can result in the retention of carbon dioxide. Clients with alveolar hypoventilation cannot increase ventilation to adjust for this increased load, and hypercapnia occurs.
Which of the following occupy space in the thorax, but do not contribute to ventilation?
Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax. Bullae may compress areas of healthier lung and impair gas exchange
Which of the following are risk factors for the development of chronic obstructive pulmonary disease (COPD)? Select all that apply
Risk factors for chronic obstructive pulmonary disease are tobacco smoke, environmental tobacco smoke, occupational dust and chemicals, indoor and outdoor air pollution, and infection.
Diaphragmatic breathing strengthens the
diaphragm during breathing
inspiratory muscle training
the client will be instructed to inhale against a set resistance for a prescribed amount of time every day in order to condition the inspiratory muscles.
An older adult client has been diagnosed with COPD. What characteristic of the client's current health status would rule out the safe and effective use of a metered-dose inhaler (MDI)?
Safe and effective MDI use requires the client to be able to manipulate the device independently, which may be difficult if the client has arthritis.
A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply
The nurse is teaching the client the technique of pursed-lip breathing. It helps slow expiration, prevents collapse of the airways, releases air trapped in the lungs, and helps the client control the rate and depth of respirations. This helps clients relax and get control of dyspnea and reduces the feelings of panic they may experience
A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take?
When a client with COPD exhibits shallow, rapid, and inefficient respirations, the nurse encourages the client to perform pursed-lip breathing, which includes exhaling slowly against pursed lips. -Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps the client control the rate and depth of respiration. - It also promotes relaxation, enabling the client to gain control of dyspnea and reduce feelings of panic.
A client is being admitted to an acute health care facility with an exacerbation of chronic obstructive pulmonary disease (COPD). The nurse is placing this information on the Medication Reconciliation Record. What medication information needs to be clarified with the health care provider?
When providing information about medications, the nurse needs to include right drug, right dose, right route, right frequency, and right time. Salmeterol/fluticasone does not include how many puffs the client is to take.
A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply
Inflamed airways that obstruct airflow Mucus secretions that block airways Overinflated alveoli that impair gas exchange - explanation: Because of chronic inflammation and the body's attempts to repair it, changes and narrowing occur in the airways. In the proximal airways, changes include increased numbers of goblet cells and enlarged submucosal glands, both of which lead to hypersecretion of mucus. In the peripheral airways, inflammation causes thickening of the airway wall, peribronchial fibrosis, exudate in the airway, and overall airway narrowing
The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient would the nurse assess first?
- NO : An 85 year old with COPD with wheezing and an O2 saturation of 89% on 2 L of oxygen - NO: A 62 year old with emphysema who has 300 mL of intravenous fluid remaining - NO: A 74 year old with chronic bronchitis who has BP 128/58, HR 104, and R 26 - YES: An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office , WHY: On the patient's arrival at the emergency department, the first line of treatment is supplemental oxygen therapy and rapid assessment to determine if the exacerbation is life-threatening. Pulse oximetry is helpful in assessing response to therapy but does not assess PaCO2 levels. The fluids will not run out during the very beginning of the shift. The vital signs listed are normal findings for patients with COPD.
