Chapter 20: Management of Patients with Chronic Pulmonary Disease

Question 1

1. A nurse is caring for a 21-year-old client whose medical history includes an
   alpha1-antitrypsin deficiency. This client has an increased risk of which health problem?
   A. Pulmonary edema
   B. Panacinar emphysema
   C. Cystic fibrosis (CF)
   D. Empyema

Answer 1

ANS: B
Rationale: This deficiency predisposes young adult clients to rapid development of panacinar lobular emphysema, even in the absence of smoking. Alpha-antitrypsin deficiency is a genetic disorder that may affect the lungs or liver. It is a risk factor for chronic obstructive pulmonary disease. Alpha1-antitrypsin is an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency does not influence the client’s risk of pulmonary edema, CF, or empyema.

Question 2

2. The nurse is assessing a client whose respiratory disease is characterized by chronic
   hyperinflation of the lungs. Which physical characteristic would the nurse most likely
   observe in this client?
   A. Signs of oxygen toxicity
   B. A moon face
   C. A barrel chest
   D. Long, thin fingers

Answer 2

ANS: C
Rationale: In chronic obstructive pulmonary disease (COPD) clients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax
configuration. The client with COPD is more likely to have finger clubbing, which is an abnormal rounded appearance of the fingertips, rather than long, thin fingers. Clubbed
fingers are the result of chronically low blood levels of oxygen. A moon face is swelling of the face due to increased fat deposits. This may be a sign of Cushing syndrome or a side effect of steroid use. Signs of oxygen toxicity, such as facial pallor or behavioral changes, may be possible but are not the most likely physical findings for this client.

Question 3

3. The nurse is providing care for a client who has recently been diagnosed with chronic
   obstructive pulmonary disease. When educating the client about exacerbations, the
   nurse should prioritize which topic?
   A. Identifying specific causes of exacerbations
   B. Prompt administration of corticosteroids during exacerbations
   C. The importance of prone positioning during exacerbations
   D. The relationship between activity level and exacerbations

Answer 3

ANS: A
Rationale: Prevention is key in the management of exacerbations, and it is important for the client to identify which factors cause exacerbations. Corticosteroids are not normally used as a “rescue” medication, and prone positioning does not enhance oxygenation. Activity in the morning may need to be delayed for an hour or two for bronchial secretions that have collected overnight in the lungs to clear. Therefore, the right amount of activity, at the right time, can impact exacerbations, but prevention is the priority.

Question 4

4. A school nurse is caring for a 10-year-old client who is having an asthma attack. What
   is the preferred intervention to alleviate this client’s airflow obstruction?
   A. Administer corticosteroids by metered dose inhaler.
   B. Administer inhaled anticholinergics.
   C. Administer an inhaled beta-adrenergic agonist.
   D. Use a peak flow monitoring device.

Answer 4

ANS: C
Rationale: Asthma exacerbations are best managed by early treatment and education of the client. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in clients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.

Question 5

5. A nurse is developing a teaching plan for an adult client with asthma. Which teaching
   point should have the highest priority in the plan of care that the nurse is developing?
   A. Gradually increase levels of physical exertion.
   B. Change filters on heaters and air conditioners frequently.
   C. Take prescribed medications as scheduled.
   D. Avoid goose-down pillows.

Answer 5

ANS: C
Rationale: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.

Question 6

6. A nurse is preparing to care for a client with bronchiectasis. The nurse should recognize
   that this client is likely to experience respiratory difficulties related to what
   pathophysiologic process?
   A. Intermittent episodes of acute bronchospasm
   B. Alveolar distention and impaired diffusion
   C. Dilation of bronchi and bronchioles
   D. Excessive gas exchange in the bronchioles

Answer 6

ANS: C
Rationale: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles that results from destruction of muscles and elastic connective tissue. It is not characterized by acute bronchospasm, alveolar distention, or excessive gas exchange.

Question 7

7. A nurse is caring for a 6-year-old client with cystic fibrosis. To enhance the child’s
   nutritional status, which priority intervention should be included in the plan of care?
   A. Pancreatic enzyme supplementation with meals
   B. Provision of five to six small meals per day rather than three larger meals
   C. Total parenteral nutrition (TPN)
   D. Magnesium, thiamine, and iron supplementation

Answer 7

ANS: A
Rationale: Nearly 90% of clients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals. Frequent, small meals or
TPN are not normally indicated. Vitamin supplements are required, but specific replacement of magnesium, thiamine, and iron is not typical.

Question 8

8. The nurse is caring for a client with bronchiectasis. Chest auscultation reveals the
   presence of copious secretions. What intervention should the nurse prioritize in this
   client’s care?
   A. Oral administration of diuretics
   B. Intravenous fluids to reduce the viscosity of secretions
   C. Postural chest drainage
   D. Pulmonary function testing

Answer 8

ANS: C
Rationale: Postural drainage is part of all treatment plans for bronchiectasis, because draining of the bronchiectatic areas by gravity reduces the amount of secretions and the degree of infection. Diuretics and IV fluids will not aid in the mobilization of secretions. Lung function testing may be indicated, but this assessment will not relieve the client’s
symptoms.

Question 9

9. A nurse is completing a focused respiratory assessment of a child with asthma. What
   assessment finding is most closely associated with the characteristic signs and
   symptoms of asthma?
   A. Shallow respirations
   B. Increased anterior–posterior (AP) diameter
   C. Bilateral wheezes
   D. Bradypnea

Answer 9

ANS: C
Rationale: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed
airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child’s AP diameter does not normally change.

Question 10

10. A nurse is developing the teaching portion of a care plan for a client with COPD. What
    would be the most important component for the nurse to emphasize?
    A. Smoking up to three cigarettes weekly is generally allowable.
    B. Chronic inhalation of indoor toxins can cause lung damage.
    C. Minor respiratory infections are considered to be self-limited and are not treated
    with medication.
    D. Activities of daily living (ADLs) should be clustered in the early morning hours.

Answer 10

ANS: B
Rationale: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution.
Smoking cessation should be taught to all clients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can
produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit clients to perform these without excessive distress.

Question 11

11. A nurse is planning the care of a client with emphysema who will soon be discharged.
    What teaching should the nurse prioritize in the plan of care?
    A. Taking prophylactic antibiotics as prescribed
    B. Adhering to the treatment regimen in order to cure the disease
    C. Avoiding airplanes, buses, and other crowded public places
    D. Setting realistic short- and long-term goals

Answer 11

ANS: D
Rationale: A major area of teaching involves setting and accepting realistic short-term and long-term goals. Emphysema is not considered curable and antibiotics are not used on a preventative basis. The client does not normally need to avoid public places.

Question 12

12. A nurse is performing a focused assessment on a client with bronchiectasis. Which are
    the most prevalent signs and symptoms of this condition? Select all that apply.
    A. Radiating chest pain
    B. Wheezes on auscultation
    C. Increased anterior–posterior (AP) diameter
    D. Copious, purulent sputum
    E. Chronic cough

Answer 12

ANS: D, E
Rationale: Characteristic symptoms of bronchiectasis include clubbing of the fingers, chronic cough, and production of purulent sputum in copious amounts. Radiating chest
pain, along with additional clinical indicators, are more indicative of a cardiovascular condition. Wheezes on auscultation are common in clients with asthma. An increased AP diameter is noted in clients with chronic obstructive pulmonary disease.

Question 13

13. A client with chronic obstructive pulmonary disease (COPD) reports increased
    shortness of breath after a prolonged episode of coughing. On assessment, the nurse
    notes an oxygen saturation of 84%, asymmetrical chest movement, and decreased
    breath sounds on the right side. Which condition should the nurse suspect and which
    interventions should the nurse implement based on these signs and symptoms?
    A. Expected response to coughing; give supplemental oxygen and encourage deep
    breathing exercises
    B. Pneumothorax; give supplemental oxygen and continue to monitor the client
    C. Oxygen toxicity; lower any supplemental oxygen and continue to monitor the
    client
    D. Chronic atelectasis; give supplemental oxygen and encourage deep breathing
    exercises

Answer 13

ANS: B
Rationale: Development of a pneumothorax, a potentially life-threatening complication of COPD, may be spontaneous or related to severe coughing or large intrathoracic
pressure changes. The combination of asymmetry of chest movement, differences in breath sounds, and a decreased pulse oximetry are indications of pneumothorax. In
response, the nurse should administer supplemental oxygen and continue close bedside monitoring of this client. The signs and symptoms described are not normal findings after
coughing or due to chronic atelectasis (alveolar collapse). While a decrease in saturation is expected after coughing, due to irritation of airways and decreased ability to fully
oxygenate, the saturation was lower than expected. Oxygen toxicity occurs when too high of a concentration of oxygen is given over a period of time, which triggers a severe
inflammatory response. Because no specific duration or amount of oxygen was listed and a hallmark of this condition is substernal discomfort and progressive respiratory difficulties, this was an unlikely choice.

Question 14

14. A nurse has been asked to give a workshop on chronic obstructive pulmonary disease
    for a local community group. The nurse emphasizes the importance of smoking cessation
    because smoking has which pathophysiologic effect?
    A. Increases the amount of mucus produced
    B. Destabilizes hemoglobin
    C. Shrinks the alveoli in the lungs
    D. Collapses the alveoli in the lungs

Answer 14

ANS: A
Rationale: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage
to the lung. Smoking is not known to destabilize hemoglobin, shrink the alveoli in the lungs, or collapse the alveoli in the lungs.

Question 15

15. A pediatric nurse practitioner is caring for a 2-year-old client who has just been
    diagnosed with asthma. The nurse has provided the parents with information that
    includes potential causative agents for an asthmatic reaction. Which potential causative
    agent that may trigger an attack should the nurse describe?
    A. Household pets
    B. Inadequate sleep
    C. Psychosocial stress
    D. Bacteria

Answer 15

ANS: A
Rationale: Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Although some research
links inadequate sleep to making asthma worse, it is not a common trigger for attacks. Psychosocial stress is anything that translates to a perceived threat to social status. Stress is listed as a trigger for asthma, but this type of stress is unlikely in a 2-year-old client. A viral, not bacterial, component is linked to asthma triggers.

Question 16

16. A nurse is providing discharge teaching for a client with COPD. What should the nurse
    teach the client about breathing exercises?
    A. Lie supine to facilitate air entry.
    B. Avoid pursed-lip breathing unless absolutely necessary.
    C. Use diaphragmatic breathing.
    D. Use chest breathing.

Answer 16

ANS: C
Rationale: Inspiratory muscle training and breathing retraining may help improve breathing patterns in clients with COPD. Training in diaphragmatic breathing reduces the
respiratory rate, increases alveolar ventilation, and helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small
airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing.

Question 17

17. A nurse is caring for a client who has been admitted with an exacerbation of chronic
    bronchiectasis. The nurse should expect to assess the client for which clinical
    manifestation?
    A. Hemoptysis
    B. Pain on inspiration
    C. Pigeon chest
    D. Dry cough

Answer 17

ANS: A
Rationale: Clinical manifestations of bronchiectasis include hemoptysis, chronic cough, copious purulent sputum, and clubbing of the fingers. Because of the copious production
of sputum, the cough is rarely dry. A pigeon chest or pectus carinatum is a deformity of the chest wall, with children and adolescents being typically affected. Pigeon chest is not
associated with this disease. Pain on inspiration is usually associated with respiratory conditions such as pleurisy, pneumonia, or pneumothorax.

Question 18

18. A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a
    new admission. The nurse should identify what characteristic aspects of CF?
    A. Alveolar mucus plugging, infection, and eventual bronchiectasis
    B. Bronchial mucus plugging, inflammation, and eventual bronchiectasis
    C. Atelectasis, infection, and eventual COPD
    D. Bronchial mucus plugging, infection, and eventual COPD

Answer 18

ANS: B
Rationale: The hallmark pathology of CF is bronchial mucus plugging, inflammation, and eventual bronchiectasis. Commonly, the bronchiectasis begins in the upper lobes and
progresses to involve all lobes. Infection, atelectasis, and COPD are not hallmark pathologies of CF.

Question 19

19. A 67-year-old client with severe bilateral arthritis of the hands has been diagnosed
    with chronic obstructive pulmonary disease. Which inhalation delivery method is best for
    the bronchodilator ordered for this client?
    A. A conventional pressurized metered-dose inhaler (pMDI)
    B. A small-volume nebulizer (SVN)
    C. A breath-actuated pressurized metered-dose inhaler (pMDI)
    D. A dry-powder inhaler (DPI)

Answer 19

ANS: B
Rationale: A SVN is the best choice for the client with severe arthritis in both hands. The SVN is a machine that mixes the medication and turns it into a mist. The client then uses
a handheld apparatus or mask and just breathes in the treatment. Any pMDI requires dexterity between inspiration and the mechanics of the inhaler to be effective. Although
DPIs rely solely on inspiration for medication delivery, they still require the user to press a button or lever to dispense the medication. Poor inhaler technique has been linked to a
lack of symptom control.

Question 20

20. A nurse is preparing to perform an admission assessment on a client with chronic
    obstructive pulmonary disease (COPD). It is most important for the nurse to review
    which of the following?
    A. Social work assessment
    B. Finances
    C. Chloride levels
    D. Available diagnostic tests

Answer 20

ANS: D
Rationale: In addition to the client’s history, the nurse reviews the results of available diagnostic tests. Social work assessment is not a priority for the majority of clients.
Chloride levels are relevant to cystic fibrosis, not COPD. Immediate physiological status would be more important than finances.

Question 21

21. A client with chronic obstructive pulmonary disease has recently begun a new
    bronchodilator. Which therapeutic effect(s) should the nurse expect from this
    medication? Select all that apply.
    A. Negative sputum culture
    B. Increased viscosity of lung secretions
    C. Increased respiratory rate
    D. Increased expiratory flow rate
    E. Relief of dyspnea

Answer 21

ANS: D, E
Rationale: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale,
and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a
worsening of the client’s respiratory status. Bronchodilators would not have a direct result on the client’s infectious process.

Question 22

22. A nurse’s assessment reveals that a client with chronic obstructive pulmonary disease
    may be experiencing bronchospasm. Which assessment findings would suggest that the
    client is experiencing bronchospasm? Select all that apply.
    A. Fine or coarse crackles on auscultation
    B. Wheezes or diminished breath sounds on auscultation
    C. Reduced respiratory rate or lethargy
    D. Slow, deliberate respirations and diaphoresis
    E. Labored and rapid breathing

Answer 22

ANS: B, E
Rationale: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies.
Bronchospasm usually results in rapid, labored breathing and agitation, not slow, deliberate respirations, reduced respiratory rate, or lethargy.

Question 23

23. The hospital case manager for a group of recently discharged clients with asthma is
    providing health education. Which aspect of client teaching would have the greatest
    impact on preventing readmissions?
    A. Alternative treatment modalities
    B. Family participation in care
    C. Pathophysiology of the disease process
    D. Self-care and the therapeutic regimen

Answer 23

ANS: D
Rationale: Knowledge about self-care and the therapeutic regimen would have the greatest impact on preventing admissions. For clients, the ability to understand the
complex therapies of inhalers, anti-allergy and anti-reflux medications, and avoidance measures are essential for long-term control. Knowledge of alternative treatment
modalities, such herbs, vitamins, or yoga, may help but is usually most effective as a complementary measure to an existing plan. Involving the family in care is important and
can help the client with compliance, support, and encouragement, but ultimately the client is responsible for their own health. Understanding the pathophysiology of the
disease process is important to include in education as it provides a better understanding in regards to causation and how it affects the body. However, how to physically manage
asthma takes precedence over understanding in terms of readmission strategies.

Question 24

24. A nurse is developing a teaching plan for a client with chronic obstructive pulmonary
    disease. What should the nurse include as the most important area of teaching?
    A. Avoiding extremes of heat and cold
    B. Setting and accepting realistic short- and long-term goals
    C. Adopting a lifestyle of moderate activity
    D. Avoiding emotional disturbances and stressful situations

Answer 24

ANS: B
Rationale: A major area of teaching involves setting and accepting realistic short- and long-term goals. The other options should also be included in the teaching plan, but they are not areas that are as high a priority as setting and accepting realistic goals.

Question 25

25. A nurse is assessing a client who is suspected of having bronchiectasis. The nurse
    should consider which of the following potential causes? Select all that apply.
    A. Pulmonary hypertension
    B. Airway obstruction
    C. Pulmonary infections
    D. Genetic disorders
    E. Atelectasis

Answer 25

ANS: B, C, D
Rationale: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis. Bronchiectasis is not caused by pulmonary hypertension or atelectasis.

Question 26

26. A nurse is planning the care of a client with bronchiectasis. What goal of care should
    the nurse prioritize?
    A. The client will successfully mobilize pulmonary secretions.
    B. The client will maintain an oxygen saturation level of 98%.
    C. The client’s pulmonary blood pressure will decrease to within reference ranges.
    D. The client will resume prediagnosis level of function within 72 hours.

Answer 26

ANS: A
Rationale: Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Pulmonary pressures are not a central focus in the care of
the client with bronchiectasis. Rapid resumption of prediagnosis function and oxygen saturation above 98% are unrealistic goals.

Question 27

27. An interdisciplinary team is planning the care of a client with bronchiectasis. What
    aspects of care should the nurse anticipate? Select all that apply.
    A. Occupational therapy
    B. Antimicrobial therapy
    C. Positive pressure isolation
    D. Chest physiotherapy
    E. Smoking cessation

Answer 27

ANS: B, D, E
Rationale: Chest physiotherapy, antibiotics, and smoking cessation are cornerstones of the care of clients with bronchiectasis. Occupational therapy and isolation are not
normally indicated.

Question 28

28. A client’s severe asthma has necessitated the use of a long-acting beta2-agonist
    (LABA). Which of the client’s statements suggests a correct understanding of this
    medication?
    A. “This drug may make my heart beat slower.”
    B. “This drug is particularly good at preventing asthma attacks during exercise.”
    C. “I’ll make sure to use this each time I feel an asthma attack coming on.”
    D. “I understand that this drug is less effective at controlling night-time
    symptoms.”

Answer 28

ANS: B
Rationale: LABAs are effective in the prevention of exercise-induced asthma. They are also used with anti-inflammatory medications to control asthma symptoms, particularly
those that occur during the night. LABAs are not indicated for immediate relief of symptoms. are not used for management of acute asthma symptoms. Tachycardia, not
bradycardia, is a potential adverse effect of this medication.

Question 29

29. A nurse is providing health education to the family of a client with bronchiectasis.
    Which technique should the nurse prioritize teaching the client’s family members?
    A. The correct technique for chest palpation and auscultation
    B. Techniques for assessing the client’s fluid balance
    C. The technique for providing deep nasotracheal suctioning
    D. The correct technique for providing postural drainage

Answer 29

ANS: D
Rationale: A focus of the care of bronchiectasis is helping clients clear pulmonary secretions; consequently, clients and families are taught to perform postural drainage. Chest palpation and auscultation and assessment of fluid balance are not prioritized over postural drainage. Nasotracheal suctioning is not normally necessary.

Question 30

30. A nurse is working with a 10-year-old client who is undergoing a diagnostic workup
    for suspected asthma. Which signs and symptoms are consistent with a diagnosis of
    asthma? Select all that apply.
    A. Chest tightness
    B. Crackles
    C. Bradypnea
    D. Wheezing
    E. Cough

Answer 30

ANS: A, D, E
Rationale: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.

Question 31

31. A nurse is developing a care plan for a client with chronic obstructive pulmonary
    disease (COPD) admitted to the hospital for the second time this year with pneumonia.
    Which nursing diagnoses would be appropriate for this client? Select all that apply.
    A. Ineffective airway clearance related to inhalation of toxins
    B. Activity intolerance related to oxygen supply and demand
    C. Impaired gas exchange related to ventilation-perfusion inequality
    D. Ineffective health management related to fatigue
    E. Deficient knowledge regarding self-care related to preventable complications

Answer 31

ANS: C, E
Rationale: Impaired gas exchange and deficient knowledge are the appropriate diagnoses for this client based on the information provided. Pneumonia is an acute
infection of the parenchyma whose pathophysiology typically triggers an inflammatory response in the lung. In a client with COPD who already has chronic inflammation, gas
exchange becomes further compromised. Areas of the lung receive either oxygen but no blood flow or blood flow but no oxygen (ventilation/perfusion inequality). Because this
was the second admission for the same diagnosis, deficient knowledge of prevention strategies should be included for this client. Although ineffective airway clearance is a
possibility, not enough information is provided to conclude that it was a result of toxins such as cigarette smoke. Activity intolerance and health management should be addressed as a risk because pneumonia and COPD impact activity and cause fatigue, but not enough information was provided to make these a problem.

Question 32

32. A nurse is teaching a client with asthma about the proper use of the prescribed
    inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client
    teaching?
    A. Increased respiratory secretions
    B. Bradycardia
    C. Oral candidiasis
    D. Decreased level of consciousness

Answer 32

ANS: C
Rationale: Thrush or oral candidiasis is a fungal infection that presents with white lesions on the tongue and/or inner cheeks of the mouth. Clients should rinse their mouth after
administration or use a spacer to prevent thrush, a common complication associated with use of inhaled corticosteroids. Increased respiratory secretions normally do not occur,
although a cough may develop. Tachycardia, or a fast heart rate, rather than bradycardia, or a slow heart rate, is listed as an adverse effect. A decreased level of consciousness is not associated with this medication because it does not cause sedation nor is it an opiate.

Question 33

33. A nurse is explaining to a client with asthma with a new prescription for prednisone
    what it is used for. What would be the most accurate explanation that the nurse could
    give?
    A. To ensure long-term prevention of asthma exacerbations
    B. To cure any systemic infection underlying asthma attacks
    C. To prevent recurrent pulmonary infections
    D. To gain prompt control of inadequately controlled, persistent asthma

Answer 33

ANS: D
Rationale: Prednisone is used for a short-term (3–10 days) “burst” to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to
prevent exacerbations in the long term.

Question 34

34. An asthma nurse educator is working with a group of adolescent asthma clients. What
    intervention is most likely to prevent asthma exacerbations among these clients?
    A. Encouraging clients to carry a corticosteroid rescue inhaler at all times
    B. Educating clients about recognizing and avoiding asthma triggers
    C. Teaching clients to utilize alternative therapies in asthma management
    D. Ensuring that clients keep their immunizations up to date

Answer 34

ANS: B
Rationale: Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate clients
about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue
inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not
necessarily prevent asthma exacerbations.

Question 35

35. An asthma educator is teaching a client newly diagnosed with asthma and the family
    about the use of a peak flow meter. The educator should teach the client that a peak flow
    meter measures highest airflow during which type of breath?
    A. Forced inspiration
    B. Forced expiration
    C. Normal inspiration
    D. Normal expiration

Answer 35

ANS: B
Rationale: Peak flow meters measure the highest airflow during a forced expiration.

Question 36

36. A nurse is admitting a new client who has been admitted with a diagnosis of COPD
    exacerbation. How can the nurse best help the client achieve the goal of maintaining
    effective oxygenation?
    A. Teach the client strategies for promoting diaphragmatic breathing.
    B. Administer supplementary oxygen by simple face mask.
    C. Teach the client to perform airway suctioning.
    D. Assist the client in developing an appropriate exercise program.

Answer 36

ANS: A
Rationale: The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With
practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps
expel as much air as possible during expiration. Suctioning is not normally necessary in clients with COPD. Supplementary oxygen is not normally delivered by simple face mask
and exercise may or may not be appropriate.

Question 37

37. A client’s plan of care specifies postural drainage. Which action should the nurse
    perform when providing this noninvasive therapy?
    A. Administer the treatment with the client in a high Fowler or semi-Fowler
    position.
    B. Perform the procedure immediately following the client’s meals.
    C. The client is instructed to avoid coughing during the therapy.
    D. Assist the client into a position that will allow gravity to move secretions.

Answer 37

ANS: D
Rationale: In postural drainage, the client assumes a position that allows gravity to facilitate the draining of secretions from all areas of the lungs. Postural drainage is
usually performed two to four times per day, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Because the client usually sits in an upright position (i.e., high- or semi-Fowler position), secretions are likely to accumulate in the lower parts of the lungs. Several other positions are used in postural drainage so that the force of gravity helps move secretions from the smaller bronchial airways to the main bronchi and trachea. The client is encouraged to cough and remove secretions during postural drainage.

Question 38

38. The home care nurse is assessing a client who requires home oxygen therapy. What
    criterion indicates that an oxygen concentrator will best meet the needs of the client in
    the home environment?
    A. The client desires a low-maintenance oxygen delivery system that delivers
    oxygen flow rates up to 6 L/min.
    B. The client requires a high-flow system for use with a tracheostomy collar.
    C. The client desires a portable oxygen delivery system that can deliver 2 L/min.
    D. The client’s respiratory status requires a system that provides an FiO2 of 65%.

Answer 38

ANS: C
Rationale: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1
to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The client desiring a portable oxygen delivery
system of 2 L/min will benefit from the use of an oxygen concentrator.

Question 39

39. A client with a severe exacerbation of chronic obstructive pulmonary disease requires
    reliable and precise oxygen delivery. Which mask will the nurse expect the health care
    provider to prescribe?
    A. Nonrebreathing mask
    B. Tracheostomy collar
    C. Venturi mask
    D. Face tent

Answer 39

ANS: C
Rationale: The Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means. It is used primarily for
clients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The Venturi mask uses the Bernoulli principle of air entrainment (trapping the air like a vacuum), which provides a high airflow with controlled oxygen enrichment. For each liter of oxygen that passes through a jet orifice, a fixed proportion of room air is entrained. Varying the size of the jet orifice and adjusting the flow of oxygen can deliver a precise volume of oxygen. The other methods of oxygen delivery listed, the nonrebreathing mask, tracheostomy collar, and face tent, do not use the Bernoulli principle and thus lack the precision of a Venturi mask.

Question 40

40. The nurse is caring for a client who is experiencing mild shortness of breath during
    the immediate postoperative period, with oxygen saturation readings between 89% and
    91%. Which method of oxygen delivery is most appropriate for the client’s needs?
    A. Nonrebreathing mask
    B. Nasal cannula
    C. Venturi mask
    D. Partial-rebreathing mask

Answer 40

ANS: B
Rationale: A nasal cannula is used when the client requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for clients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The client’s respiratory status does not require a partial- or non-rebreathing mask.