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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.
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After the nurse has finished teaching a patient about pursed lip breathing, which of the following patient actions indicate that more teaching is needed?
- A. The patient inhales slowly through the nose.
- B. The patient tenses the neck muscles while exhaling.
- C. The patient practises by blowing through a straw.
- D. The patient's ratio of inhalation to exhalation is 1:3.
Correct Answer: B
Rationale: The patient should relax the neck and shoulder muscles while doing pursed lip breathing. The other actions by the patient indicate a good understanding of pursed lip breathing.
The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about exercise. Which of the following information should the nurse include?
- A. Stop exercising if you start to feel short of breath.'
- B. Use the bronchodilator before you start to exercise.'
- C. Breathe in and out through the mouth while you exercise.'
- D. Upper body exercise should be avoided to prevent dyspnea.'
Correct Answer: B
Rationale: Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.
Which of the following findings by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?
- A. Pulse oximetry reading of 91.9%.
- B. Absence of wheezes or crackles.
- C. Decreased use of accessory muscles.
- D. Respiratory rate of 22 breaths/minute.
Correct Answer: A
Rationale: For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with asthma. Which of the following patients require the most rapid action by the nurse?
- A. 20-year-old with ABG results: pH 7.28, PaCO2: 60 mm Hg, and PaO2: 58 mm Hg.
- B. 32-year-old with ABG results: pH 7.30, PaCO2: 30 mm Hg, and PaO2: 65 mm Hg.
- C. 40-year-old with ABG results: pH 7.34, PaCO2: 33 mm Hg, and PaO2: 80 mm Hg.
- D. 64-year-old with ABG results: pH 7.31, PaCO2: 58 mm Hg, and PaO2: 64 mm Hg.
Correct Answer: A
Rationale: The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible, but do not require interventions as quickly as the 20-year-old.
The nurse is caring for a patient with chronic bronchitis who has a new prescription for a combined fluticasone and salmeterol inhaler and the patient asks the nurse the purpose of using two drugs. Which of the following information is the basis for the nurse's response?
- A. One drug decreases inflammation, and the other is a bronchodilator.
- B. It is a combination of long-acting and slow-acting bronchodilators.
- C. The combination of two drugs works more quickly in an acute asthma attack.
- D. The two drugs work together to block the effects of histamine on the bronchioles.
Correct Answer: A
Rationale: Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks. Neither medication is an antihistamine. The two-drug combination of salmeterol and fluticasone is not used during an acute attack because the medications do not work rapidly.