Nokea
A nurse is documenting the results of assessment of a patient with bronchiectasis. What would the nurse most likely include in documentation?
- A. Sudden onset of pleuritic chest pain
- B. Wheezes on auscultation
- C. Increased anterior-posterior (A-P) diameter
- D. Clubbing of the fingers
Correct Answer: D
Rationale: Characteristic symptoms of bronchiectasis include chronic cough and production of purulent sputum in copious amounts. Clubbing of the fingers also is common because of respiratory insufficiency. Sudden pleuritic chest pain is a common manifestation of a pulmonary embolism. Wheezes on auscultation are common in patients with asthma. An increased A-P diameter is noted in patients with COPD.
You may also like to solve these questions
A patient arrives in the emergency department with an attack of acute bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this patients care?
- A. Oral administration of diuretics
- B. Intravenous fluids to reduce the viscosity of secretions
- C. Postural chest drainage
- D. Pulmonary function testing
Correct Answer: C
Rationale: Postural drainage is part of all treatment plans for bronchiectasis, because draining of the bronchiectatic areas by gravity reduces the amount of secretions and the degree of infection. Diuretics and IV fluids will not aid in the mobilization of secretions. Lung function testing may be indicated, but this assessment will not relieve the patients symptoms.
A nurse is caring for a patient with COPD. The patients medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status?
- A. Negative sputum culture
- B. Increased viscosity of lung secretions
- C. Increased respiratory rate
- D. Increased expiratory flow rate
- E. Relief of dyspnea
Correct Answer: 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 patients respiratory status. Bronchodilators would not have a direct result on the patients infectious process.
A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse prioritize?
- A. The patient will successfully mobilize pulmonary secretions.
- B. The patient will maintain an oxygen saturation level of 98%.
- C. The patients pulmonary blood pressure will decrease to within reference ranges.
- D. The patient will resume prediagnosis level of function within 72 hours.
Correct Answer: A
Rationale: Nursing management focuses on alleviating symptoms and helping patients clear pulmonary secretions. Pulmonary pressures are not a central focus in the care of the patient with bronchiectasis. Rapid resumption of prediagnosis function and oxygen saturation above 98% are unrealistic goals.
A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give?
- A. To ensure long-term prevention of asthma exacerbations
- B. To cure any systemic infection underlying asthma attacks
- C. To prevent recurrent pulmonary infections
- D. To gain prompt control of inadequately controlled, persistent asthma
Correct Answer: D
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.
A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD?
- A. Lung cancer
- B. Cystic fibrosis
- C. Respiratory failure
- D. Hemothorax
Correct Answer: C
Rationale: Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (cor pulmonale). Lung cancer, cystic fibrosis, and hemothorax are not common complications.