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An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what?
- A. Kyphosis and clubbing of the fingers
- B. Dyspnea and hypoxemia
- C. Sepsis and pneumothorax
- D. Bradypnea and pursed lip breathing
Correct Answer: B
Rationale: These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications. Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea.
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A nurse is assessing a patient who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes?
- A. Pulmonary hypertension
- B. Airway obstruction
- C. Pulmonary infections
- D. Genetic disorders
- E. Atelectasis
Correct Answer: B,C,D
Rationale: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis. Bronchiectasis is not caused by pulmonary hypertension or atelectasis.
A patient with emphysema is experiencing shortness of breath. To relieve this patients symptoms, the nurse should assist her into what position?
- A. Sitting upright, leaning forward slightly
- B. Low Fowlers, with the neck slightly hyperextended
- C. Prone
- D. Trendelenburg
Correct Answer: A
Rationale: The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe. Low Fowlers positioning would be less likely to aid oxygenation. Prone or Trendelenburg positioning would exacerbate shortness of breath.
A nurse is caring for a 6-year-old patient with cystic fibrosis. In order to enhance the childs nutritional status, what intervention should most likely be included in the plan of care?
- A. Pancreatic enzyme supplementation with meals
- B. Provision of five to six small meals per day rather than three larger meals
- C. Total parenteral nutrition (TPN)
- D. Magnesium, thiamine, and iron supplementation
Correct Answer: A
Rationale: Nearly 90% of patients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals. Frequent, small meals or TPN are not normally indicated. Vitamin supplements are required, but specific replacement of magnesium, thiamine, and iron is not typical.
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 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.