Chapter 31: Obstructive Pulmonary Diseases

The nurse is caring for a client with chronic bronchitis who has a new prescription for a
combined fluticasone and salmeterol inhaler and the client asks the nurse the purpose of
using two drugs. Which of the following information is the basis for the nurse's response?

a. One drug decreases inflammation, and the other is a bronchodilator.
b. It is a combination of long-acting and slow-acting bronchodilators.
c. The combination of two drugs works more quickly in an acute asthma attack.
d. The two drugs work together to block the effects of histamine on the bronchioles.

ANS: A
Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work
together to prevent asthma attacks. Neither medication is an antihistamine. The two-drug
combination of salmeterol and fluticasone is not used during an acute attack because the
medications do not work rapidly.

The nurse has completed client teaching about the administration of salmeterol using a
metered-dose inhaler (MDI). Which of the following actions by the client indicates good
understanding of the teaching?

a. The client attaches a spacer before using the MDI.
b. The client coughs vigorously after using the inhaler.
c. The client floats the MDI in water to see if it is empty.
d. The client activates the inhaler at the onset of expiration.

ANS: A
Spacers can improve the delivery of medication to the lower airways. The other client
actions indicate a need for further teaching.

The nurse is preparing a client with possible asthma for pulmonary function testing. Which
of the following instructions should the nurse include in the teaching plan?

a. Avoid eating or drinking for several hours before the testing.
b. Use rescue medications immediately before the tests are done.
c. Take oral corticosteroids at least 2 hours before the examination.
d. Withhold bronchodilators for 6-12 hours before the examination.

ANS: D
Bronchodilators are held before pulmonary function testing so that a baseline assessment
of airway function can be determined. Testing is repeated after bronchodilator use to
determine whether the decrease in lung function is reversible. There is no need for the
client to be NPO. Oral corticosteroids also should be held before the examination and
corticosteroids given 2 hours before the examination would be at a high level. Rescue
medications (which are bronchodilators) would not be given until after the baseline
pulmonary function was assessed.

Which of the following information should the nurse include when teaching the client with
asthma about the prescribed medications?

a. Utilize the inhaled corticosteroid when shortness of breath occurs.
b. Inhale slowly and deeply when using the dry-powder inhaler (DPI).
c. Hold your breath for 5 seconds after using the bronchodilator inhaler.
d. Tremors are an expected adverse effect of rapidly acting bronchodilators.

ANS: D
Tremors are a common adverse effect of short-acting b2-adrenergic (SABA) medications
and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act
rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The client should
hold the breath for 10 seconds after using inhalers.

The nurse is evaluating the effectiveness of therapy for a client who has received treatment
during an asthma attack. Which of the following findings is the best indicator that the
therapy has been effective?

a. No wheezes are audible.
b. Oxygen saturation is >92%.
c. Accessory muscle use has decreased.
d. Respiratory rate is 16 breaths/minute.

ANS: B
The goal for treatment of an asthma attack is to keep the oxygen saturation >92%. The
other client data may occur when the client is too fatigued to continue with the increased
work of breathing required in an asthma attack.

The nurse is assessing a client in the asthma clinic who has recorded daily peak flows that
are 85% of the baseline. Which of the following actions should the nurse plan to take?

a. Teach the client about the use of oral corticosteroids.
b. Administer a bronchodilator and recheck the peak flow.
c. Instruct the client to continue to use current medications.
d. Evaluate whether the peak flowmeter is being used correctly.

ANS: C
The client's peak flow readings indicate good asthma control (values over 80%), and no
changes are needed. The other actions would be used for clients in the yellow or red zones
for peak flow.

Which of the following actions by a client who has asthma indicates a good understanding
of the nurse's teaching about peak flowmeter use?

a. The client records an average of three peak flow readings every day.
b. The client inhales rapidly through the peak flowmeter mouthpiece.
c. The client uses the albuterol metered-dose inhaler (MDI) for peak flows in the
yellow zone.
d. The client calls the health care provider when the peak flow is in the green zone.

ANS: C
Readings in the yellow zone indicate a decrease in peak flow; the client should use
short-acting b2-adrenergic (SABA) medications. The best of three peak flow readings
should be recorded. Readings in the green zone indicate good asthma control. The client
should exhale quickly and forcefully through the peak flowmeter mouthpiece to obtain the
readings.

The nurse is assessing a young adult client in the outpatient clinic who has a new diagnosis
of emphysema and does not have a history of smoking. Which of the following
information should the nurse anticipate teaching the client about?

a. a1-antitrypsin testing
b. Use of the nicotine patch
c. Continuous pulse oximetry
d. Effects of leukotriene modifiers

ANS: A
When emphysema occurs in young clients, especially without a smoking history, a
congenital deficiency in a1-antitrypsin should be suspected. Because the client does not
smoke, a nicotine patch would not be ordered. There is no indication that the client
requires continuous pulse oximetry. Leukotriene modifiers would be used in clients with
asthma, not with emphysema.

Which of the following information about a newly admitted client with chronic obstructive
pulmonary disease (COPD) indicates that the nurse should consult with the health care
provider before administering the prescribed theophylline?

a. The client has had a recent 10-pound weight gain.
b. The client has a cough productive of green mucus.
c. The client denies any shortness of breath at present.
d. The client takes cimetidine 150 mg daily.

ANS: D
Cimetidine interferes with the metabolism of theophylline, and concomitant administration
may lead rapidly to theophylline toxicity. The other client information would not impact
on whether the theophylline should be administered or not.

The nurse is caring for a client with chronic bronchitis who has a nursing diagnosis of
impaired breathing pattern related to anxiety. Which of the following nursing actions is
best to include in the plan of care?

a. Titrate oxygen to keep saturation at least 90%.
b. Discuss a high-protein, high-calorie diet with the client.
c. Suggest the use of over-the-counter sedative medications.
d. Teach the client how to effectively use pursed lip breathing.

ANS: D
Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and
decrease air trapping. There is no indication that the client requires oxygen therapy or an
improved diet. Sedative medications should be avoided because they decrease respiratory
drive.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which of the
following interventions is best to address this problem?

a. Increase the client's intake of fruits and fruit juices.
b. Have the client exercise for 10 minutes before meals.
c. Assist the client in choosing foods with a lot of texture.
d. Offer high calorie snacks between meals and at bedtime.

ANS: D
Eating small amounts more frequently (as occurs with snacking) will increase caloric
intake by decreasing the fatigue and feelings of fullness associated with large meals.
Clients with COPD should rest before meals. Foods that have a lot of texture may take
more energy to eat and lead to decreased intake. Although fruits and juices are not
contraindicated, foods high in protein are a better choice.

The nurse is interviewing a client with a new diagnosis of chronic obstructive pulmonary
disease (COPD). Which of the following information will help most in confirming a
diagnosis of chronic bronchitis?

a. The client tells the nurse about a family history of bronchitis.
b. The client's history indicates a 40 pack-year cigarette history.
c. The client denies having any respiratory problems until the last 6 months.
d. The client complains about a productive cough every winter for 3 months.

ANS: D
A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3
months for at least 2 consecutive years. There is no familial tendency for chronic
bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking
history does not confirm the diagnosis.

After the nurse has finished teaching a client about pursed lip breathing, which of the
following client actions indicates that more teaching is needed?

a. The client inhales slowly through the nose.
b. The client tenses the neck muscles while exhaling.
c. The client practices by blowing through a straw.
d. The client's ratio of inhalation to exhalation is 1:3.

ANS: B
The client should relax the neck and shoulder muscles while doing pursed lip breathing.
The other actions by the client indicate a good understanding of pursed lip breathing

Which of the following findings by the nurse for a client with a nursing diagnosis of
impaired gas exchange will be most useful in evaluating the effectiveness of treatment?

a. Pulse oximetry reading of 91%
b. Absence of wheezes or crackles
c. Decreased use of accessory muscles
d. Respiratory rate of 22 breaths/minute

ANS: A
For the nursing diagnosis of impaired gas exchange, the best data for evaluation are
arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either
improvement or impending respiratory failure caused by fatigue.

The nurse is evaluating the effectiveness of therapy for a client with cor pulmonale. Which
of the following findings should the nurse assess for in the client?

a. Elevated temperature
b. Clubbing of the fingers
c. Jugular vein distension
d. Complaints of chest pain

ANS: C
Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular
vein distension. The other clinical manifestations may occur in the client with other
complications of chronic obstructive pulmonary disease (COPD) but are not indicators of
cor pulmonale.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
is receiving oxygen. Which of the following actions is best for the nurse to implement to
determine the appropriate oxygen flow rate?

a. Minimize oxygen use to avoid oxygen dependency.
b. Maintain the pulse oximetry level at 90% or greater.
c. Administer oxygen according to the client's level of dyspnea.
d. Avoid administration of oxygen at a rate of more than 2 L/minute.

ANS: B
The best way to determine the appropriate oxygen flow rate is by monitoring the client's
oxygenation either by arterial blood gases (ABGs) or pulse oximetry; an oxygen saturation
of 90% indicates adequate blood oxygen level without the danger of suppressing the
respiratory drive. For clients with an exacerbation of COPD, an oxygen flow rate of 2
L/minute may not be adequate. Because oxygen use improves survival rate in clients with
COPD, there is not a concern about oxygen dependency. The client's perceived dyspnea
level may be affected by other factors (such as anxiety) besides blood oxygen level.

Which of the following information should the nurse include in teaching a client with
chronic obstructive pulmonary disease (COPD) who has a new prescription for home
oxygen therapy?

a. Storage of oxygen tanks will require adequate space in the home.
b. Travel opportunities will be limited because of the use of oxygen.
c. Oxygen flow should be increased if the client has more dyspnea.
d. Oxygen use can improve the client's prognosis and quality of life.

ANS: D
Research supports the use of home oxygen to improve quality of life and prognosis. Since
increased dyspnea may be a symptom of an acute process such as pneumonia, the client
should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes
worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on
individual client circumstances. Travel is possible by using portable oxygen concentrators.

The nurse is caring for a client who is receiving 35% oxygen via a Venturi mask. To
ensure the correct amount of oxygen delivery, it is most important that the nurse
implement which of the following actions?

a. Keep the air entrainment ports clean and unobstructed.
b. Give a high enough flow rate to keep the bag from collapsing.
c. Use an appropriate adaptor to ensure adequate oxygen delivery.
d. Drain moisture condensation from the oxygen tubing every hour.

ANS: A
The air entrainment ports regulate the oxygen percentage delivered to the client, so they
must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial
rebreather or nonrebreather masks. The use of an adaptor can improve humidification but
not oxygen delivery. Draining oxygen tubing is necessary when caring for a client
receiving mechanical ventilation.

Which of the following information should the nurse teach a client with COPD?

a. To exercise immediately before a meal
b. To eat a high-calorie, low-protein diet
c. To have 5 or 6 small meals a day
d. Avoid foods that are cooked in a microwave

ANS: C
Eating five to six small meals per day helps avoid feelings of bloating and early satiety.
The use of frozen foods and a microwave oven may help conserve a client's energy in
food preparation. Exercises should be avoided for at least 1 hour before and after eating. A
high-calorie, high-protein diet is recommended.

The nurse is developing a teaching plan to help increase activity tolerance at home for a
70-year-old client with severe chronic obstructive pulmonary disease (COPD). Which of the following exercise goals should the nurse teach the client?

a. Walk until pulse rate exceeds 130.
b. Walk for a total of 20 minutes daily.
c. Exercise until shortness of breath occurs.
d. Limit exercise to activities of daily living (ADLs).

ANS: B
The goal for exercise programs for clients with COPD is to increase exercise time
gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and
not an indication that the client should stop. Limiting exercise to ADLs will not improve
the client's exercise tolerance. A 70-year-old client should have a pulse rate of 120 or less
with exercise (80% of the maximal heart rate of 150).

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD)
who tells the nurse, "I wish I were dead! I cannot do anything for myself anymore." Based
on this information, which of the following nursing diagnoses is best?

a. Hopelessness related to chronic stress (expectation of death)
b. Ineffective coping related to insufficient sense of control
c. Deficient knowledge related insufficient information (education about COPD)
d. Social isolation related to insufficient personal resources (increased physical

ANS: D
The client's statement about not being able to do anything for themselves supports this
diagnosis. Emotions frequently encountered include guilt, depression, anxiety, social
isolation, denial, and dependence. Although deficient knowledge, hopelessness, and
ineffective coping also may be appropriate diagnoses for clients with COPD, the data for
this client do not support these diagnoses.

The nurse is admitting a client with chronic obstructive pulmonary disease (COPD) to the
hospital. Which of the following positions should the nurse place the client in to improve
gas exchange?

a. Resting in bed with the head elevated to 45-60 degrees
b. Sitting up at the bedside in a chair and leaning slightly forward
c. Resting in bed in a high Fowler's position with the knees flexed
d. In the Trendelenburg position with several pillows behind the head

ANS: B
Clients with COPD improve the mechanics of breathing by sitting up in the "tripod"
position. Resting in bed with the head elevated would be an alternative position if the
client was confined to bed, but sitting in a chair allows better ventilation. The
Trendelenburg position or sitting upright in bed with the knees flexed would decrease the
client's ability to ventilate well.

Which of the following diagnostic tests should the nurse plan to discuss with a client who
has progressively increasing dyspnea and is being evaluated for a possible diagnosis of
chronic obstructive pulmonary disease (COPD)?

a. Eosinophil count
b. Spirometry
c. Immunoglobin E (IgE) levels
d. Radioallergosorbent test (RAST)

ANS: B
The diagnosis of COPD is confirmed by spirometry regardless of whether the client has
chronic symptoms. The other tests would be used to test for an allergic component for
asthma, but will not be used in the diagnosis of COPD.

Which of the following actions should be included in the plan of care for a client with
cystic fibrosis (CF) who is admitted to the hospital with increased dyspnea?

a. Schedule a sweat chloride test.
b. Arrange for a hospice nurse visit.
c. Place the client on a low-sodium diet.
d. Perform chest physiotherapy every 4 hours.

ANS: D
Routine scheduling of airway clearance techniques is an essential intervention for clients
with CF. A sweat chloride test is used to diagnose CF, but it does not provide any
information about the effectiveness of therapy. There is no indication that the client is
terminally ill. Clients with CF lose excessive sodium in their sweat and require high
amounts of dietary sodium.

The nurse is caring for a client who is hospitalized with cystic fibrosis (CF) and is
coughing up large quantities of thick green mucus. Which of the following treatments
should the nurse include in the teaching plan?

a. Antibiotic resistance
b. Inhaled bronchodilators
c. Oral corticosteroid therapy
d. Aerosolized amoxicillin

ANS: D
The colour of the mucus and the client's history of CF suggest Pseudomonas infection; an
antibiotic is required. Oral corticosteroids and inhaled bronchodilators will not be effective
in treating the respiratory infection; the effectiveness of bronchodilators has not been
established for CF. Pseudomonas infections are usually responsive (not resistant) to TOBI.

A young adult client with cystic fibrosis (CF) tells the nurse that she is considering having
a child. Which of the following responses is best for the nurse to respond initially?

a. "Are you aware of the normal lifespan for clients with CF?"
b. "Do you need any information to help you with the decision?"
c. "You will need to have genetic counselling before making a decision."
d. "Many women with CF do not have difficulty in conceiving children."

ANS: B
The nurse's initial response should be to assess the client's knowledge level and need for
information. Although the lifespan for clients with CF is likely to be shorter than normal,
it would not be appropriate for the nurse to address this as the initial response to the
client's comments. The other responses are accurate, but the nurse should first assess the
client's understanding about the issues surrounding pregnancy.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which of the
following nursing actions is best?

a. Change the oxygen flow rate to the highest prescribed rate.
b. Reinforce the ongoing use of pursed lip breathing techniques.
c. Educate the client to use the Flutter airway clearance device.
d. Teach the client about consistent use of inhaled corticosteroids.

ANS: C
Airway clearance devices assist with moving mucus into larger airways where it can more
easily be expectorated. The other actions may be appropriate for some clients with COPD,
but they are not indicated for this client's problem of thick mucous secretions.

After the nurse has completed diet teaching for a client with chronic obstructive
pulmonary disease (COPD) who has a body mass index (BMI) of 20, which of the
following client statements indicate that the teaching has been effective?

a. "I will drink lots of fluids with my meals."
b. "I will have ice cream as a snack every day."
c. "I will exercise for 15 minutes before meals."
d. "I will decrease my intake of meat or poultry."

ANS: B
High-calorie foods like ice cream are an appropriate snack for clients with COPD. Fluid
intake of 3 L/day is recommended, but fluids should be taken between meals rather than
with meals to improve oral intake of solid foods. The client should avoid exercise for an
hour before meals to prevent fatigue while eating. Meat and dairy products are high in
protein and are good choices for the client with COPD.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about
exercise. Which of the following information should the nurse include?

a. "Stop exercising if you start to feel short of breath."
b. "Use the bronchodilator before you start to exercise."
c. "Breathe in and out through the mouth while you exercise."
d. "Upper body exercise should be avoided to prevent dyspnea."

ANS: B
Use of a bronchodilator before exercise improves airflow for some clients and is
recommended. Shortness of breath is normal with exercise and not a reason to stop.
Clients should be taught to breathe in through the nose and out through the mouth (using a
pursed lip technique). Upper-body exercise can improve the mechanics of breathing in
clients with COPD.

Which of the following information given by a client with asthma while the nurse is doing
the admission assessment is most indicative of a need for a change in therapy?

a. The client uses terbutaline before any aerobic exercise.
b. The client says that the asthma symptoms are worse every spring.
c. The client's heart rate increases after using the salbutamol inhaler.
d. The client's only medications are formoterol and salmeterol.

ANS: D
Long-acting b2-agonists should be used only in clients who also are using an inhaled
corticosteroid for long-term control. The other information given by the client requires
further assessment by the nurse but is not unusual for a client with asthma.

The nurse is conducting an admission history for a client with possible asthma who has
new-onset wheezing and shortness of breath. Which of the following information indicates
a need for a change in therapy?

a. The client has a history of pneumonia 2 years ago.
b. The client has chronic inflammatory bowel disease.
c. The client takes propranolol for hypertension.
d. The client uses acetaminophen for headaches.

ANS: C
b-Blockers such as propranolol can cause bronchospasm in some clients. The other
information will be documented in the health history but does not indicate a need for a
change in therapy.

Which of the following topics should the nurse include in medication teaching for a client
with newly diagnosed persistent asthma?

a. Use of long-acting b-adrenergic medications
b. Adverse effects of sustained-release theophylline
c. Self-administration of inhaled corticosteroids
d. Complications associated with oxygen therapy

ANS: C
Inhaled corticosteroids are more effective in improving asthma than any other drug and are
indicated for all clients with persistent asthma. The other therapies would not typically be
first-line treatments for newly diagnosed asthma.

The nurse is caring for a client with cystic fibrosis (CF) who has blood glucose levels that
are consistently 11-14 mmol/L. Which of the following nursing actions should the nurse
plan to implement?

a. Discuss the role of diet in blood glucose control.
b. Educate the client about administration of insulin.
c. Give oral hypoglycemic medications before meals.
d. Evaluate the client's home use of pancreatic enzymes.

ANS: B
The glucose levels indicate that the client has developed CF-related diabetes; insulin
therapy will be required. Since the etiology of diabetes in CF is inadequate insulin
production, oral hypoglycemic agents are not effective. Clients with CF need a
high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of
hyperglycemia in a client with CF.

The nurse is caring for a client with a history of asthma. Which of the following
assessments finding should the nurse communicate immediately to the health care
provider?

a. Pulse oximetry reading of 91%
b. Respiratory rate of 26 breaths/minute
c. Use of accessory muscles in breathing
d. Peak expiratory flow rate of 240 mL/minute

ANS: C
Use of accessory muscle indicates that the client is experiencing respiratory distress and
rapid intervention is needed. The other data indicate the need for ongoing monitoring and
assessment but do not suggest that immediate treatment is required.

35. Which of the following actions should the nurse anticipate taking first when a client who
is experiencing an asthma attack develops bradycardia and a decrease in wheezing?

a. Assist with endotracheal intubation.
b. Document changes in respiratory status.
c. Encourage the client to cough and deep breathe.
d. Administer IV methylprednisolone.

ANS: A
The client's assessment indicates impending respiratory failure, and the nurse should
prepare to assist with intubation and mechanical ventilation. IV corticosteroids require
several hours before having any effect on respiratory status. The client will not be able to
cough or deep breathe effectively. Documentation is not a priority at this time.

The nurse is caring for a client in the emergency department who is experiencing an acute asthma attack. After listening to the client's breath sounds, which of the following actions should the nurse take next?

a. Start an intravenous with Ringer's Lactate.
b. Ask about inhaled corticosteroid use.
c. Determine when the dyspnea started.
d. Obtain the forced expiratory volume (FEV) flow rate.

ANS: D
The examiner can assess the degree of severity by measuring FEV1 or PEFR, identifying
the degree of change in objective measurements, and evaluating the baseline pulse
oximetry value. The length of time the attack has persisted is not as important as
determining the client's status at present. It is important to know about the medications the
client is using but not as important as assessing the breath sounds. Initiating IV therapy is
not a priority at this time.

Which of the following findings in a client who has received omalizumab is considered an
adverse effect?

a. Pain at injection site
b. Flushing and dizziness
c. Respiratory rate 22 breaths/minute
d. Peak flow reading 75% of normal

ANS: A
Reaction at injection site is the only adverse effect of omalizumab. The other information
is not related to omalizumab therapy.

The nurse is teaching a client about continuous home oxygen use and cautions the client to
take extra care to not run out of oxygen. Which of the following seasons should the nurse
instruct the client has the highest rate of oxygen evaporation?

a. Spring
b. Summer
c. Fall
d. Winter

ANS: B
During the summer, with liquid oxygen, evaporation is accelerated and may decrease
reservoir duration to less than 1 week.

The nurse is caring for a client with asthma who has a baseline peak flow reading of 600
mL and calls the nurse, stating that the current peak flow is 420 mL. Which of the
following actions should the nurse take first?

a. Tell the client to go to the hospital emergency department.
b. Instruct the client to use the prescribed albuterol.
c. Ask about recent exposure to any new allergens or asthma triggers.
d. Question the client about use of the prescribed inhaled corticosteroids.

ANS: B
The client's peak flow is 70% of normal, in the yellow zone, indicating a need for
immediate use of short-acting b2-adrenergic SABA medications. Assessing for correct use
of medications or exposure to allergens also is appropriate, but would not address the
current decrease in peak flow. Because the client is currently in the yellow zone,
hospitalization is not needed.

The following medications are prescribed by the health care provider for a client having an
acute asthma attack. Which medication should the nurse administer first?

a. Salmeterol 50 mcg per dry-powder inhaler (DPI)
b. Salbutamol 2.5 mg per nebulizer
c. Triamcinolone 2 puffs per metered-dose inhaler (MDI)
d. Methylprednisolone 60 mg IV

ANS: B
Salbutamol is a rapidly acting bronchodilator and is the first-line medication to reverse
airway narrowing in acute asthma attacks. It is known as an asthma rescue medication.
The other medications work more slowly.