Chapter 30: Care of Patients with Noninfectious Lower Respiratory Problems Flashcards
A nurse cares for a client who has a family history of cystic fibrosis. The client asks, “Will my children have cystic fibrosis?” How would the nurse respond?
“Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested.”
Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated
for the disorder to be expressed. The nurse would encourage both the client and partner to be
tested for the abnormal gene
A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action?
Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system.
Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous
system. This allows the sympathetic nervous system to dominate and release norepinephrine that activates beta2 receptors.
A nurse evaluates the following arterial blood gas and vital sign results for a client with
chronic obstructive pulmonary disease (COPD):
Arterial Blood Gas Results pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L (28 mmol/L)
Vital Signs: Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76%
What action would the nurse take first?
Initiate oxygenation therapy to increase saturation to 88% to 92%.
Oxygen would be administered to a client who is hypoxic even if the client has COPD and is a
carbon dioxide retainer.
A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.)
Administer oxygen and place client on an oximeter.
Administer prescribed albuterol inhaler.
Assess the client’s lung sounds after administering the inhaler.
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is becoming unstable, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would reassess the lung sounds after the rescue inhaler
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse’s immediate intervention? (Select all that apply.)
Tracheal deviation
Sudden onset of shortness of breath
Drainage greater than 70 mL/hr
Disconnection at Y site
Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing.
A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available.
A 27-year-old client with a heart rate of 120 beats/min
A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?
Ask about medications the client is currently taking
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This
results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory
pathways and is a high priority given the clients history.
After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching?
I will take this medication every morning to help prevent an acute attack
Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting.
The client will take this medication every day for best effect.
A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client?
Omelet, soft whole wheat bread.
Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements.
The nurse is caring for a client with lung cancer who states, I dont want any pain medication because I am afraid Ill become addicted. How should the nurse respond?
It is unlikely you will become addicted when taking medicine for pain.
Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain.
After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?
I will use the drug when I have an asthma attack
Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the clients part allows the drug to escape through the nose and mouth
A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?
Share any thoughts and feelings that cause you to limit social activities.
Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be
selected.
A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this
clients teaching?
Eat a well-balanced, nutritious diet
Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining
nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
Cover the insertion site with sterile gauze.
Immediately covering the insertion site helps prevent air from entering the pleural space and causing a
pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action
should the nurse take?
Encourage oral rinsing after fluticasone administration.
The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection.
A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?
Keep the client isolated from other clients with cystic fibrosis.
Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the
client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?
Administer pain medication and encourage the client to take deep breaths
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide
pain medication to minimize discomfort and encourage the client to take deep breaths.
A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a
pneumothorax?
When the tube becomes disconnected from the drainage system
Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected
from the drainage system, air can be sucked into the pleural space and cause a pneumothorax.
