COPD

Question 1

The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, what finding indicates to the nurse that the patient’s respiratory status is improving?

Wheezing becomes louder.
Cough remains nonproductive.
Vesicular breath sounds decrease.
Aerosol bronchodilators stimulate coughing.

Answer 1

Wheezing becomes louder.

The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.

Question 2

During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change?
Laryngospasm
Pulmonary edema
Narrowing of the airway
Overdistention of the alveoli

Answer 2

Narrowing of the airway
Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing.
Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing

Question 3

A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma?
Anxiety
Cyanosis
Bradycardia
Hypercapnia

Answer 3

Anxiety

An early manifestation during an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.

Question 4

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient?
Allow time to calm the patient.
Observe for signs of diaphoresis.
Evaluate the use of intercostal muscles.
Monitor the patient for bilateral chest expansion.

Answer 4

Evaluate the use of intercostal muscles.

The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.

Question 5

Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation?
Supine
Lithotomy
High Fowler's
Reverse Trendelenburg

Answer 5

High Fowler’s
The patient experiencing an asthma attack should be placed in high Fowler’s position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.

Question 6

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis?
Work of breathing
Fear of suffocation
Effects of medications
Anxiety and restlessness

Answer 6

Work of breathing
When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.

Question 7

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 what as the most likely next step in treatment?
IV fluids
Biofeedback therapy
Systemic corticosteroids
Pulmonary function testing

Answer 7

Systemic corticosteroids
Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used, but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.

Question 8

A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use?
Oxygen tent
Venturi mask
Nasal cannula
Oxygen-conserving cannula

Answer 8

Venturi mask
The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.

Question 9

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

Answer 9

Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse.

It is important to keep track of peak flow readings daily, especially when the patient’s symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter and should be assessed before and after medications to evaluate their effectiveness.

Question 10

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?
“Close lips tightly around the mouthpiece and breathe in deeply and quickly.”
“To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it.”
“You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs.”
“Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible.”

Answer 10

“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.

Question 11

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after what occurs?
Hypertension and pulmonary edema
Oropharyngeal candidiasis and hoarseness
Elevation of blood glucose and calcium levels
Adrenocortical dysfunction and hyperglycemia

Answer 11

Oropharyngeal candidiasis and hoarseness
Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.

Question 12

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit?
“I will pay less for medication because it will last longer.”
“More of the medication will get down into my lungs to help my breathing.”
“Now I will not need to breathe in as deeply when taking the inhaler medications.”
“This device will make it so much easier and faster to take my inhaled medications.”

Answer 12

More of the medication will get down into my lungs to help my breathing.”
A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler.

Question 13

Which test result identifies that a patient with asthma is responding to treatment?
An increase in CO2 levels
A decreased exhaled nitric oxide
A decrease in white blood cell count
An increase in serum bicarbonate levels

Answer 13

A decreased exhaled nitric oxide
Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in the asthma patient.

Question 14

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign?
Pulse rate of 72/minute
Temperature of 98.4° F
Oxygen saturation 96%
Respiratory rate of 18/minute

Answer 14

Pulse rate of 72/minute
Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 indicates that the patient did not experience tachycardia as an adverse effect.

Question 15

The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack?
Albuterol (Proventil)
Salmeterol (Serevent)
Beclomethasone (Qvar)
Ipratropium bromide (Atrovent)

Answer 15

Albuterol (Proventil)
Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide (Atrovent) is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).

Question 16

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters?
Apical pulse
Daily weight
Bowel sounds
Deep tendon reflexes

Answer 16

Daily weight
Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient’s daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes.

Question 17

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

Answer 17

Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychologic factors, and gastroesophageal reflux disease (GERD).

Question 18

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication?
Chew a hard candy before the first puff of medication.
Rinse the mouth with water before each puff of medication.
Ask for a breath mint following the second puff of medication.
Rinse the mouth with water following the second puff of medication.

Answer 18

Rinse the mouth with water following the second puff of medication.
Because beclamethosone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.

Question 19

The nurse is evaluating if a patient understands how to safely determine whether a metered dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler?
Place it in water to see if it floats.
Keep track of the number of inhalations used.
Shake the canister while holding it next to the ear
Check the indicator line on the side of the canister.

Answer 19

Keep track of the number of inhalations used.

It is no longer appropriate to see if a canister floats in water or not since this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used. (100 puffs/2 puffs each day = 50 days)

Question 20

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease?
An overproduction of the antiprotease α1-antitrypsin
Hyperinflation of alveoli and destruction of alveolar walls
Hypertrophy and hyperplasia of goblet cells in the bronchi
Collapse and hypoventilation of the terminal respiratory unit

Answer 20

Hyperinflation of alveoli and destruction of alveolar walls
In COPD there are structural changes that include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.

Question 21

A male patient with 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?
Arterial pH 7.26
PaCO2 50 mm Hg
Patient in tripod position
Increased sputum expectoration

Answer 21

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.

Question 22

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

Answer 22

Effective and productive coughing
Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.

Question 23

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient?
Order fruits and fruit juices to be offered between meals.
Order a high-calorie, high-protein diet with six small meals a day.
Teach the patient to use frozen meals at home that can be microwaved.
Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

Answer 23

Order a high-calorie, high-protein diet with six small meals a day.
Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day taking in a high-calorie, high-protein diet, with non-protein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient’s caloric intake.

Question 24

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?
Loosening secretions so that they may be coughed up more easily
Promoting maximal inhalation for better oxygenation of the lungs
Preventing bronchial collapse and air trapping in the lungs during exhalation
Increasing the respiratory rate and giving the patient control of respiratory patterns

Answer 24

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.

Question 25

Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)?
Acute respiratory failure
Secondary respiratory infection
Fluid volume excess resulting from cor pulmonale
Pulmonary edema caused by left-sided heart failure

Answer 25

Fluid volume excess resulting from cor pulmonale
Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.

Question 26

A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse?
“Long-term home oxygen therapy should be used to prevent respiratory failure.”
“Oxygen will not be needed until or unless you are in the terminal stages of this disease.”
“Long-term home oxygen therapy should be used to prevent heart problems related to COPD.”
“You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia.”

Answer 26

“You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia.”

Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.

Question 27

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

Answer 27

Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.
The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 - patient’s age).

Question 28

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

Answer 28

Increased peak flow readings

Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates (PEFRs).

Question 29

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

Answer 29

“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.

Question 30

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections?
Smoking causes a hoarse voice.
Cough will become nonproductive.
Decreased alveolar macrophage function
Sense of smell is decreased with smoking.

Answer 30

Decreased alveolar macrophage function
The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.

Question 31

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

Answer 31

Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed.
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.

Question 32

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included?
Increasing dyspnea
Temperature below 98.6° F
Decreased sputum production
Unable to drink 3 L low-sodium fluids

Answer 32

Increasing dyspnea
The significant clinical manifestations to report to the health care provider include increasing dyspnea, fever, chills, increased sputum production, bloody sputum, and chest pain. Although drinking at least 3 L of low-sodium fluid will help liquefy secretions to make them easier to expectorate, the health care provider does not need to be notified if the patient cannot do this one day.