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A client who is experiencing an acute asthmatic attack receives prescribed therapy with a bronchodilator. As part of the plan of care, the nurse would continue to assess which of the following every 4 hours? Select all that apply.
- A. Intake
- B. Blood pressure
- C. Output
- D. Lung sounds
- E. Accessory muscle use
Correct Answer: A,C,D,E
Rationale: The nurse should note the client's respiratory rate, lung sounds, intake, and output and use of accessory muscles in breathing every 4 hours during an acute asthma attack.
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During stable chronic phases of asthma, the nurse should advise the client to monitor which of the following? Select all that apply.
- A. Blood pressure
- B. Wheezing
- C. Respiratory rate
- D. Coughing
- E. Peak flow changes
Correct Answer: B,D,E
Rationale: Clients with chronic stable asthma should monitor for symptoms such as wheezing, coughing, peak flow changes, and things that might be making the asthma worse.
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.
A client is demonstrating how to use a peak flow meter. The nurse determines that the client is successful when he does which of the following? Select all that apply.
- A. Inhales as forcibly as possible
- B. Stands upright to allow the best inhalation possible
- C. Makes sure indicator is at lowest level on scale
- D. Makes sure lips are sealed tightly around the mouthpiece
- E. Measures peak flow rate at different times each day
Correct Answer: B,C,D
Rationale: When teaching a client to use a peak flow meter, instruct the client to make sure the indicator is at the lowest level, stand upright, make sure the lips form a tight seal around the mouthpiece, exhale as forcibly and as quickly as possible, and test peak flow at the same time each day.
After teaching a group of nursing students about xanthine derivatives, the instructor determines that the teaching was successful when the students state which of the following? Select all that apply.
- A. Xanthine derivatives cause flushing.
- B. The action of xanthine derivatives leads to bradycardia.
- C. Xanthine derivatives cause a reduction in airway inflammation.
- D. Xanthine derivatives cause hypoglycemia.
- E. Xanthine derivatives stimulate the CNS to promote bronchodilation.
Correct Answer: A,E
Rationale: Xanthine derivatives can cause flushing, tachycardia, and hyperglycemia. Xanthine derivatives elicit their effects by stimulating the CNS to promote bronchodilation.
A client is prescribed zileuton (Zyflo). The nurse instructs the client to contact the primary health care provider if which of the following occur? Select all that apply.
- A. Jaundice
- B. Pruritus
- C. Fatigue
- D. Dizziness
- E. Restlessness
Correct Answer: A,B,C
Rationale: Zileuton may cause liver damage, which may present with the following symptoms: upper right quadrant pain, nausea, fatigue, lethargy, pruritus, and jaundice.