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The nurse is caring for a patient with a history of asthma. Which of the following assessment findings should the nurse communicate immediately to the health care provider?
- A. Pulse oximetry reading of 94%.
- B. Respiratory rate of 26 breaths/minute.
- C. Use of accessory muscles in breathing.
- D. Peak expiratory flow rate of 240 mL/minute.
Correct Answer: C
Rationale: Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.
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The nurse is assessing a young adult patient in the outpatient clinic who has a new diagnosis of emphysema and does not have a history of smoking. Which of the following information should the nurse anticipate teaching the patient about?
- A. ?±1-antitrypsin testing
- B. Use of the nicotine patch
- C. Techniques for smoking cessation
- D. Avoidance of upper respiratory infections
Correct Answer: A
Rationale: Since the patient does not have a history of smoking, ?±1-antitrypsin deficiency is a likely cause of early-onset emphysema and should be investigated. The other options are not relevant since the patient is a non-smoker, and there is no indication of current respiratory infections.
Which of the following information should the nurse include in teaching a patient with chronic obstructive pulmonary disease (COPD) who has a new prescription for home oxygen therapy?
- A. Storage of oxygen tanks will require adequate space in the home.
- B. Travel opportunities will be limited because of the use of oxygen.
- C. Oxygen flow should be increased if the patient has dyspnea.
- D. Oxygen use can improve the patient's quality of life and survival.
Correct Answer: D
Rationale: Research shows that oxygen use can improve quality of life and survival in patients with COPD. Storage considerations, travel limitations, and oxygen flow adjustments require specific guidance, but the primary benefit to emphasize is the improvement in quality of life and survival.
The nurse is teaching a patient about continuous home oxygen use and cautions the patient to take extra care to not run out of oxygen. Which of the following seasons should the nurse instruct the patient has the highest rate of oxygen evaporation?
- A. Spring.
- B. Summer.
- C. Fall.
- D. Winter.
Correct Answer: B
Rationale: During the summer, with liquid oxygen, evaporation is accelerated and may decrease reservoir duration to less than 1 week.
The nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which of the following findings is the best indicator that the therapy has been effective?
- A. No wheezes are audible.
- B. Oxygen saturation is >95%.
- C. Accessory muscle use has decreased.
- D. Respiratory rate is 16 breaths/minute.
Correct Answer: B
Rationale: The goal for treatment of an asthma attack is to keep the oxygen saturation >92%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which of the following nursing actions is best?
- A. Change the oxygen flow rate to the highest prescribed rate.
- B. Reinforce the ongoing use of pursed lip breathing techniques.
- C. Educate the patient to use the Flutter airway clearance device.
- D. Teach the patient about consistent use of inhaled corticosteroids.
Correct Answer: C
Rationale: Airway clearance devices assist with moving mucus into larger airways where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not as effective for addressing rhonchi and nonproductive cough.