The nurse is teaching the client with a pulmonary disorder about deep breathing

Chapter 20: Management of Patients with Chronic Pulmonary Disease

1. A nurse is caring for a 21-year-old client whose medical history includes an alpha 1 -antitrypsin deficiency. This client has an increased risk of which health problem?

A. Pulmonary edema B. Panacinar emphysema C. Cystic fibrosis (CF) D. Empyema

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. Alpha 1 -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.

1. 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

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.

1. 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

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.

1. 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.

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.

1. 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.

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.

1. 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

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.

1. 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

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.

1. 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

B. Nasal cannula C. Venturi mask D. Partial-rebreathing mask

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.

1. 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

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.

1. 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

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.

1. 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

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.

1. 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.

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.

1. 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

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.

1. 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

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.

1. 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)

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 FiO 2 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.

1. 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

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.

1. 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

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.

1. 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.

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., 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.

1. 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.

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.

1. 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

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.

1. A client's severe asthma has necessitated the use of a long-acting beta 2 -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."

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.

1. 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

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.

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.

Multiple Choice

1. 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

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.

1. 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

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.

1. 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

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.

1. 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

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.

1. 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

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.

1. 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

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.

1. 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