NCLEX 3 Oxygenation Mod 15 Flashcards
The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply. A) Increased CO2 B) Vasoconstriction C) Decreased O2 D) Decreased intracranial pressure (ICP) E) Increased pulse rate
A) Increased CO2
C) Decreased O2
E) Increased pulse rate
Rationale :
Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO2). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation.
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply. A) Bounding pulse B) Pink nail beds C) Cyanosis D) Confusion E) Wheezing
C) Cyanosis
D) Confusion
Rationale :
A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.
The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply.
A) Elevate head of the bed
B) Administer a high rate of oxygen by nasal cannula
C) Prepare for a chest tube insertion
D) Administer prescribed antihypertensive medications
E) Administer intravenous caffeine per order
A) Elevate head of the bed
C) Prepare for a chest tube insertion
Rationale :
The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed because of the client’s dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse? A) Narrow bronchi B) Narrow trachea passages C) Blocked large airway passages D) Inflamed pleural surfaces
C) Blocked large airway passages
Rationale:
The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.
The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client? A) Hemoglobin level 14 g/dL B) Oxygen saturation 96% C) Serum sodium 140 mg/dL D) Blood pH 7.32
D) Blood pH 7.32
Rationale :
Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.
A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client? A) Face mask B) Nasal cannula C) Nonrebreather mask D) Venturi mask
B) Nasal cannula
Rationale:
The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.
The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate?
A) Encourage strenuous activity.
B) Consult a dietitian for low-calorie meals.
C) Space periods of activity with periods of rest.
D) Encourage dependence with activities of daily living.
C) Space periods of activity with periods of rest.
Rationale :
The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. It will often be appropriate to space periods of activity with periods of rest. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living.
The nurse is providing care for a client admitted during an acute exacerbation of asthma. Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client? A) Inhaled short-acting beta-agonists B) Oral corticosteroids C) Inhaled long-acting beta-agonists D) Oral anticholinergics
A) Inhaled short-acting beta-agonists
Rationale:
The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.
The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate?
A) Notify the healthcare provider of this assessment finding.
B) Obtain an arterial blood gas for further respiratory assessment.
C) Begin monitoring the respiratory rate every 5 minutes.
D) Continue to monitor the newborn per facility policy.
D) Continue to monitor the newborn per facility policy.
Rationale:
A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute. Therefore, this client only needs monitoring. No other actions are necessary.
The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply. A) Excessive rapid breathing B) Chest pain C) Rapid breathing at rest D) Shallow breathing E) Cyanosis
A) Excessive rapid breathing
C) Rapid breathing at rest
D) Shallow breathing
Rationale:
Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.
The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention?
A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
C) The newly licensed nurse is observed assessing the client’s thoracic wall, skin, and nail beds.
D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.
B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
Rationale:
The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client’s thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client’s breath sounds with the use of a stethoscope is appropriate.
Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply. A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning D) Prescribing bronchodilators E) Monitoring activity intolerance
A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
E) Monitoring activity intolerance
Rationale:
Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
The nurse is providing care to a client with arterial blood gas analysis as follows: PaO2 of 82, PaCO2 of 49, HCO3 of 26, and pH of 7.31. Which assessment by the nurse is correct? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis
A) Respiratory acidosis
Rationale:
Both the pH and the carbon dioxide levels represent acidosis. The PaO2 of 82 is on the low end of normal and the bicarbonate level is normal, indicating that this is respiratory acidosis rather than metabolic acidosis.
While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse’s hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply.
A) Remove the suction catheter
B) Lower the head of the bed
C) Decrease the suction pressure
D) Apply restraints to the client’s arms and legs
E) Hyperoxygenate the client
A) Remove the suction catheter
C) Decrease the suction pressure
E) Hyperoxygenate the client
Rationale:
The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.
The structure of the respiratory system that serves as the site of gas exchange is the A) macrophage. B) bronchi. C) alveoli. D) bronchiole.
C) alveoli.
Rationale:
The alveoli comprise the terminal structures of the lower respiratory system. Alveoli serve as the sites of gas exchange, specifically, carbon dioxide and oxygen. Bronchi and bronchioles are larger structures in the respiratory system that serve as tracts for airflow. Macrophages are immune cells that keep the alveoli region free of microbes.
Vaccinations can help promote healthy oxygenation by
A) reducing the transmission of preventable diseases.
B) increasing the exchange of oxygen for carbon dioxide in the lungs.
C) promoting adequate blood circulation to organs and tissues.
D) preventing all respiratory infections.
A) reducing the transmission of preventable diseases.
Rationale::
Vaccinations help decrease the transmission of preventable diseases, many of which are spread by respiratory secretions. Many of these diseases also affect the respiratory system and can alter oxygenation. Vaccinations do not directly increase the exchange of oxygen for carbon dioxide in the lungs, nor do they promote adequate blood circulation. Vaccinations can prevent some respiratory infections, but not all respiratory infections, and they can also prevent some nonrespiratory infections.
Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS)? A) Fluid imbalance B) Hypertension C) Bradycardia D) Dyspnea
D) Dyspnea
Rationale:
Dyspnea is a clinical manifestation of clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.
The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the client's family, what should the nurse say is the expected progression of the disease process? A) Initiation of ARDS B) Onset of pulmonary edema C) End-stage ARDS D) Alveolar collapse
A) Initiation of ARDS
B) Onset of pulmonary edema
D) Alveolar collapse
C) End-stage ARDS
Rationale:
ARDS begins with inflammatory cellular responses and biochemical mediators that damage the alveolar-capillary membrane. Increased interstitial pressure and damage to the alveolar membrane allow fluid to enter the alveoli. The inflammatory process damages surfactant-producing cells, leading to a deficit of surfactant, increased alveolar surface tension, and alveolar collapse. Multiple-organ system dysfunction of the kidneys, liver, gastrointestinal tract, central nervous system, and cardiovascular system are the leading causes of death in ARDS.
The nurse is providing care to a client with sepsis due to a severely infected leg wound. The client states that he is having trouble breathing. Upon assessment, the nurse notes dyspnea, a respiratory rate of 32, the use of accessory muscles to breathe, and rales and rhonchi upon auscultation of the lungs. The nurse recognizes these findings as characteristic of what condition?
A) Allergic response from antibiotic therapy
B) Deep vein thrombosis
C) Acute respiratory distress syndrome
D) Anemia
C) Acute respiratory distress syndrome
Rationale :
Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. Pulmonary assessment data indicate that the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.
A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client? A) Risk for Infection B) Impaired Spontaneous Ventilation C) Risk for Acute Confusion D) Decreased Cardiac Output
B) Impaired Spontaneous Ventilation
A client with acute respiratory distress syndrome (ARDS) is being weaned from ventilatory support. Which nursing actions are appropriate for this client? Select all that apply.
A) Increase percentage of oxygen being provided through the ventilator.
B) Place in the Fowler position.
C) Provide morning care during the weaning procedures.
D) Begin weaning procedures in the morning.
E) Medicate with morphine for pain as needed.
B) Place in the Fowler position.
D) Begin weaning procedures in the morning.
Rationale:
Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. The percentage of oxygen is typically reduced during the weaning process.
A client receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety related to having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply.
A) Explain about care areas specifically designed for long-term ventilatory support.
B) Dim the lights and reduce distracting noise, such as the television.
C) Instruct that intubation and ventilation are temporary measures.
D) Encourage family visits and participation in care.
E) Remain with the client as much as possible.
C) Instruct that intubation and ventilation are temporary measures.
D) Encourage family visits and participation in care.
E) Remain with the client as much as possible.
Rationale:
A critical illness creates anxiety for any client. For the client with ARDS, anxiety is compounded by intubation and mechanical ventilation. To reduce this client’s anxiety, the nurse should encourage the family to visit and participate in care. The nurse should also remain with the client as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal. Explaining that there are care areas designed for long-term ventilatory support could increase the client’s anxiety. The nurse should provide distractions such as television or radio and not dim the lights or turn off the television, which could also increase the client’s anxiety.
Which data supports the nurse’s assessment that a newborn with acute respiratory distress syndrome (ARDS) is improving?
A) Increased PaCO2
B) Oxygen saturation of 92%
C) Pulmonary vascular resistance increases
D) Thick secretions from the respiratory tract
B) Oxygen saturation of 92%
Rationale:
An expected outcome for a client being treated for ARDS is maintaining an oxygen saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen saturation of 92% is improving. Increased PaCO2, increased pulmonary vascular resistance, and thick secretions from the respiratory tract are indicative of continued distress.
The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply. A) Sepsis B) Viral pneumonia C) Drug overdose D) Near drowning in saltwater E) Fractured humerus
A) Sepsis
B) Viral pneumonia
C) Drug overdose
D) Near drowning in saltwater
Rationale:
ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, sepsis, pulmonary infections, saltwater inhalation, and drug overdose. A fractured humerus is not a risk factor for the development of ARDS.
The nurse is caring for a client admitted with septic shock. Which early clinical manifestation might indicate the development of ARDS? A) Intercostal retractions B) Cyanosis C) Tachypnea D) Tachycardia
C) Tachypnea
Rationale:
Dyspnea and tachypnea are early clinical manifestations of ARDS. As the distress progresses, the client would demonstrate an increasing respiratory rate, intercostal retractions, and use of accessory muscles, as well as tachycardia. Cyanosis is a late manifestation.
A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygenation? A) Oxygen via a nasal cannula B) Mechanical ventilation C) Oxygen via a face mask D) Oxygen via a Venturi mask
B) Mechanical ventilation
Rationale:
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. Therefore, mechanical ventilation is often necessary. Oxygen administered via nasal cannula, face mask, or venture mask all require active and adequate breathing by the client, which may not be possible for the client with ARDS.
The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a decrease of cardiac output secondary to positive pressure ventilation?
A) Blood pressure increases from 88/58 mmHg to 90/60 mmHg
B) Urine output decreases from 30 mL/hr to 25 mL/hr
C) Heart rate drops from 108 bpm to 104 bpm
D) Oxygen saturation increases from 82% to 90%
B) Urine output decreases from 30 mL/hr to 25 mL/hr
Rationale:
Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output. Expected urine output is at least 30 mL/hr. This client’s urine output is decreased; therefore, this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, both indicate improvement from the previous assessment, suggesting that they are not contributing to decreased cardiac output. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.
The nurse is providing care to a client with ARDS who has a tracheostomy. The nurse will monitor the client for complications related to the loss of which protective mechanism?
A) The ability to cough
B) Filtration and humidification of inspired air
C) Decrease in oxygen-carrying capacity of the trachea
D) The sneeze reflex initiated by irritants in the nasal passages
B) Filtration and humidification of inspired air
Rationale:
When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming provided by the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.
The client with ARDS who is likely to have the poorest outcome is
A) a Hispanic male with pneumonia.
B) an African American male with sepsis.
C) a Caucasian female with sepsis.
D) an African American female with chest trauma.
B) an African American male with sepsis.
Rationale:
The risk for mortality from ARDS is greater for men than for women, and it is greater for African Americans than people from other races. In addition, clients who develop ARDS from sepsis have poorer outcomes than clients who develop ARDS from pulmonary infections or trauma. Therefore, the African American male with ARDS from sepsis will likely have the poorest outcome.
One primary method for preventing ARDS in hospitalized clients is
A) performing postural drainage for clients with respiratory congestion.
B) elevating the head of the bed for clients who are ingesting food.
C) providing smoking cessation literature to clients who smoke.
D) administering oxygen as ordered by the healthcare provider.
B) elevating the head of the bed for clients who are ingesting food.
Rationale:
Aspiration of gastric contents is a major risk factor for developing ARDS. Therefore, simple interventions such as elevating the head of the bed for clients who are ingesting food can help prevent ARDS. Performing postural drainage and administering oxygen will not prevent ARDS. Although smoking may increase the risk for ARDS, it is not a direct cause of ARDS, so smoking cessation literature will not prevent ARDS in hospitalized clients.
The nurse is caring for a woman who is 32 weeks pregnant and requires mechanical ventilation for ARDS. In addition to standard nursing interventions for adult clients with ARDS, what special interventions need to be implemented for this client?
A) Inducing labor
B) Administering nitric oxide and corticosteroids
C) Providing nutritional support
D) Fetal monitoring
D) Fetal monitoring
Rationale:
Care for pregnant clients with ARDS who are at least at 20-24 weeks’ gestation should include close fetal monitoring for potential emergency delivery. If the ARDS leads to compromised placental oxygen transfer, the neonate should be delivered immediately for the best outcome. However, not all pregnant women with ARDS will need immediate emergency delivery of the neonate. Providing nutritional support and administering nitric oxide and corticosteroids are interventions for all adult clients with ARDS, not only pregnant women.
The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings should the nurse identify as signs that the client has progressed to respiratory failure? Select all that apply.
A) Retractions and fatigue
B) Tachycardia and tachypnea
C) Inaudible breath sounds
D) Diffuse wheezing and the use of accessory muscles when inhaling
E) Reduced wheezing and an ineffective cough
C) Inaudible breath sounds
E) Reduced wheezing and an ineffective cough
Rationale:
Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.
Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift should the nurse recommend for this client? A) A basket of flowers B) A stuffed animal C) Fruit and candy D) A book
D) A book
Rationale:
A client with asthma must not be exposed to items that can exacerbate their disease process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and items that may contain dust, such as a stuffed animal, should be avoided. Objects void of irritants, such as a book, would be an appropriate gift.
A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching?
A) “We’ll be sure to use the fireplace often to keep the house warm in the winter.”
B) “We will replace the carpet in our child’s bedroom with tile.”
C) “We’ll keep the plants in our child’s room dusted.”
D) “We’re glad the dog can continue to sleep in our child’s room.”
B) “We will replace the carpet in our child’s bedroom with tile.”
Rationale:
Control of dust in the child’s bedroom is an important aspect of environmental control for asthma management, and replacing the carpeting in the child’s bedroom with tile flooring will reduce dust. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.
A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? A) Ineffective Airway Clearance B) Impaired Tissue Perfusion C) Ineffective Breathing Pattern D) Activity Intolerance
C) Ineffective Breathing Pattern
Rationale:
The client is experiencing an increased respiratory rate and is wheezing, which is an ineffective breathing pattern. Not enough information is provided to determine whether the client has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.
A client asks why asthma medication is needed even though the client’s last attack was several months ago. Which response by the nurse is appropriate?
A) “The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack.”
B) “The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him.”
C) “The medication is still needed to decrease inflammation in your airways and help prevent an attack.”
D) “The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it.”
C) “The medication is still needed to decrease inflammation in your airways and help prevent an attack.”
Rationale:
Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs. Long-term treatment of asthma continues indefinitely, not for just 1 year. Telling a client that lungs will be severely damaged is nontherapeutic; the inability to prevent an acute attack in this client is not true. The nurse is able to answer the client’s question; it does not need to be referred to the physician.
The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this client’s teaching? Select all that apply.
A) Take no more than the prescribed number of doses each day.
B) Rinse the mouth after taking this medication.
C) Take on an empty stomach.
D) Take with meals or a full glass of water.
E) Use hard candy or drink extra fluids to help with a dry mouth.
A) Take no more than the prescribed number of doses each day.
E) Use hard candy or drink extra fluids to help with a dry mouth.
Rationale:
Appropriate teaching for a client prescribed ipratropium bromide (Atrovent) includes only taking the prescribed number of doses each day to prevent a drug overdose and the use of hard candy or extra fluids to decrease dry mouth. The mouth does not need to be rinsed after taking this medication. This medication does not need to be taken with meals or a full glass of water, or on an empty stomach.
The nurse is planning care for a young adolescent client diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care? Select all that apply.
A) Referring to a peer-led support group
B) Teaching the parents how to administer maintenance medication prior to teaching the client
C) Assessing peer support when planning care
D) Collaborating with teachers for support in the school setting
E) Telling the client to avoid medication while at school
A) Referring to a peer-led support group
C) Assessing peer support when planning care
D) Collaborating with teachers for support in the school setting
Rationale:
Age-appropriate, evidence-based interventions for a young adolescent client diagnosed with asthma include referral to a peer-led support group, assessing peer support of the client, and collaborating with teachers to ensure the client has the necessary support in the school setting. While it is appropriate to include the parents in the educational process, the client should be taught how to administer medications prior to teaching the parents. Avoiding medication administration while in school could lead to an acute asthma attack.
The nurse instructs a client with asthma on bronchodilator therapy. Which statement indicates client understanding of how the drug works?
A) “The medication widens the airways by causing airway muscle contraction.”
B) “The medication widens the airways by causing airway muscle relaxation.”
C) “The medication widens the airways by decreasing histamine production.”
D) “The medication widens the airways by decreasing mucus production.”
B) “The medication widens the airways by causing airway muscle relaxation.”
Rationale:
Bronchodilators stimulate bronchiolar smooth muscle relaxation, not contraction. Smooth muscle relaxation increases the diameter of the airway lumen to enhance airflow. Bronchodilators do not decrease the production of mucus or the production of histamine.
