Nokea
A client is prescribed albuterol for bronchospasm in chronic bronchial asthma. Which of the following nursing diagnoses would the nurse expect to see on the care plan as a result of the adverse reaction of albuterol?
- A. Anxiety
- B. Risk of Impaired Oral Mucous Membranes
- C. Ineffective Tissue Perfusion
- D. Risk of Injury
Correct Answer: A
Rationale: The nurse would most likely identify a nursing diagnosis of Anxiety related to the adverse reaction of albuterol. A nursing diagnosis of Risk of Impaired Mucous Membranes may be seen with the use of corticosteroids, which increase the risk of oral candidiasis. There is no increased risk of injury or ineffective tissue perfusion with the use of albuterol therapy.
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When describing the drugs used to treat lower respiratory system conditions, the nursing instructor discusses chronic obstructive pulmonary disease (COPD). Which condition would the instructor include when discussing this condition related to the use of these drugs? Select all that apply.
- A. Asthma
- B. Pulmonary embolism
- C. Pulmonary hypertension
- D. Chronic bronchitis
- E. Pneumonia
Correct Answer: A,D
Rationale: COPD encompasses asthma, chronic bronchitis, chronic obstructive bronchitis, emphysema, or a combination of the conditions.
A client receives a loading dose of theophylline to treat acute respiratory symptoms. When assessing the client, the nurse would immediately notify the primary health care provider for which of the following?
- A. Constipation
- B. Abdominal cramps
- C. Bradycardia
- D. Mental depression
Correct Answer: B
Rationale: It is important for the nurse to closely monitor the client for signs of theophylline toxicity. The nurse should notify the primary health care provider immediately if any of the following signs of theophylline toxicity develop: anorexia, nausea, vomiting, diarrhea, confusion, abdominal cramping, headache, restlessness, insomnia, tachycardia, arrhythmias, or seizures. Constipation, bradycardia, and mental depression are not signs of theophylline toxicity.
Before leaving the hospital after an acute asthma attack, a client is given a prescription for fluticasone/salmeterol (Advair) 250/50 to inhale one puff twice a day. The nurse completing the client's discharge teaching should tell the client which of the following? Select all that apply.
- A. Take the medication as needed.
- B. Continue to carry a rescue inhaler.
- C. Check peak flow daily.
- D. Rinse mouth after each use.
- E. Shake meter well before using.
Correct Answer: B,C,D
Rationale: The drug is a dry powder inhaler that contains an inhaled corticosteroid and a long-acting beta agonist. The medication should be taken every day as per the directions on the label to prevent future exacerbations. The client should continue to carry a rescue inhaler and check peak flow around the same time each day. Advair does not need to be shaken prior to use as it is a dry powder inhaler. The client should be advised to rinse his mouth out after each use to prevent oral thrush.
A client with asthma has been prescribed an antiasthmatic drug. Before administering the drug, the nurse assesses the respiratory rate of the client. The nurse notifies the primary health care provider based on which finding?
- A. 10 breaths/min
- B. 14 breaths/min
- C. 18 breaths/min
- D. 22 breaths/min
Correct Answer: A
Rationale: The nurse should consider 10 breaths/min an abnormal respiratory rate and notify the primary health care provider. Respiratory rates below 12 breaths/min or above 24 breaths/min are considered abnormal. A respiratory rate between 12 breaths/min and 24 breaths/min is considered normal.
A client is prescribed inhaled corticosteroid therapy along with bronchodilator therapy. Which of the following points should the nurse include in the teaching plan?
- A. Stop corticosteroid therapy immediately if you notice any adverse effects.
- B. Before each dose of corticosteroid, rinse the mouth thoroughly with water.
- C. The corticosteroid drug provides rapid relief during an asthma attack.
- D. Take the corticosteroid several minutes after the bronchodilator dose.
Correct Answer: D
Rationale: The nurse should instruct the client to take the corticosteroid several minutes after the bronchodilator dose. This helps in enhancing the application of the steroid into the bronchial tract. Corticosteroid therapy should never be stopped abruptly. The mouth should be rinsed thoroughly with water after each dose of corticosteroid to prevent the occurrence of fungal infections. The steroid drug does not provide rapid relief during an asthma attack, as it does not dilate the bronchus.