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A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.)
- A. What color is your sputum?
- B. Do you have any difficulty sleeping?
- C. How long does it take to perform your morning routine?
- D. Do you walk up stairs every day?
- E. Have you lost any weight lately?
Correct Answer: B,C,E
Rationale: Difficulty sleeping, prolonged morning routines, and weight loss indicate worsening dyspnea or fatigue, reflecting activity tolerance. Sputum color and stair climbing frequency are less directly related to activity tolerance.
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A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
- A. Administer prescribed salmeterol (Serevent) inhaler.
- B. Assess the client for tracheal deviation.
- C. Perform peak expiratory flow readings.
- D. Administer prescribed albuterol (Proventil) inhaler.
- E. Encourage diaphragmatic breathing.
Correct Answer: C,D
Rationale: Suprasternal retraction and wheezing indicate acute asthma exacerbation. Administering albuterol (a short-acting beta2 agonist) is appropriate for immediate relief, and peak flow readings help assess severity. Salmeterol is a long-acting medication, not for acute attacks. Tracheal deviation is unrelated, and diaphragmatic breathing is not a priority during an acute attack.
A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?
- A. Review the client's pulmonary function test results.
- B. Review medications the client is currently taking.
- C. Assess how frequently the client uses a bronchodilator.
- D. Consider the report of the client with asthma phases.
Correct Answer: B
Rationale: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people due to increased production of leukotrienes when aspirin or NSAIDs suppress other inflammatory pathways. This is a high-priority action given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. Assessing bronchodilator use addresses interventions for attacks but not their cause. Considering asthma phases is not a priority action.
A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, 'What does this mean?' How should the nurse respond?
- A. Your children will be at high risk for the development of chronic obstructive pulmonary disease.
- B. I will contact a genetic counselor to discuss your condition.
- C. Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke.
- D. This is a recessive gene and should have no impact on your health.
Correct Answer: C
Rationale: AAT deficiency increases the risk of COPD, particularly in smokers. Clients with one allele produce enough AAT to prevent COPD unless exposed to irritants like smoke. The risk to children depends on the partner's AAT status, and contacting a genetic counselor is not the priority response.
A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which pathophysiologic process should the nurse associate with these clinical manifestations?
- A. Increased pulmonary pressure creating a higher workload on the right side of the heart.
- B. Increased pulmonary inflammation of the bronchi and bronchioles.
- C. Increased number and size of mucus glands producing large amounts of thick mucus.
- D. Left ventricular hypertrophy creating a decrease in cardiac output.
Correct Answer: A
Rationale: Smoking can lead to pulmonary hypertension, causing cor pulmonale (right-sided heart failure). This results in increased pulmonary pressure, backing up blood into the right heart and peripheral venous system, leading to distended neck veins and edema. The other options describe different pathophysiological processes not directly linked to these symptoms.
A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take? (Select all that apply.)
- A. Keep an intravenous line dedicated strictly to the infusion.
- B. Teach the client that this medication increases pulmonary pressures.
- C. Ensure that there is always a backup drug cassette available.
- D. Start a large-bore peripheral intravenous line.
- E. Use strict aseptic technique when using the drug delivery system.
Correct Answer: A,C,E
Rationale: Prostacyclin should be administered via a dedicated central venous catheter with strict aseptic technique to prevent infection. A backup cassette is essential due to risks of interruption. The medication decreases pulmonary pressures, and a central line, not peripheral, is used.