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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.
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The nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which of the following information will help most in confirming a diagnosis of chronic bronchitis?
- A. The patient tells the nurse about a family history of bronchitis.
- B. The patient's history indicates a 40 pack-year cigarette history.
- C. The patient denies having any respiratory problems until the last 6 months.
- D. The patient complains about a productive cough every winter for 3 months.
Correct Answer: D
Rationale: A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.
Which of the following actions by a patient who has asthma indicates a good understanding of the nurse's teaching about peak flow meter use?
- A. The patient records an average of three peak flow readings every day.
- B. The patient inhales rapidly through the peak flow meter mouthpiece.
- C. The patient uses the salbutamol metered-dose inhaler (MDI) for peak flows in the yellow zone.
- D. The patient calls the health care provider when the peak flow is in the green zone.
Correct Answer: C
Rationale: Readings in the yellow zone indicate a decrease in peak flow; the patient should use short-acting β-adrenergic (SABA) medications. The best of three peak flow readings should be recorded. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings.
Which of the following actions should be included in the plan of care for a patient with cystic fibrosis (CF) who is admitted to the hospital with increased dyspnea?
- A. Schedule a sweat chloride test.
- B. Arrange for a hospice nurse visit.
- C. Place the patient on a low-sodium diet.
- D. Perform chest physiotherapy every 4 hours.
Correct Answer: D
Rationale: Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium.
The nurse is caring for a patient who is hospitalized with cystic fibrosis (CF) and is coughing up large quantities of thick green mucus. Which of the following treatments should the nurse include in the teaching plan?
- A. Antibiotic resistance.
- B. Inhaled bronchodilators.
- C. Oral corticosteroid therapy.
- D. Aerosolized amoxicillin.
Correct Answer: D
Rationale: The colour of the mucus and the patient's history of CF suggests Pseudomonas infection; an antibiotic is required. Oral corticosteroids and inhaled bronchodilators will not be effective in treating the respiratory infection; the effectiveness of bronchodilators has not been established for CF. Pseudomonas infections are usually responsive (not resistant) to TOBI.
The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD) who tells the nurse, 'I wish I were dead! I cannot do anything for myself anymore.' Based on this information, which of the following nursing diagnoses is best?
- A. Hopelessness related to chronic stress (expectation of death).
- B. Ineffective coping related to insufficient sense of control.
- C. Deficient knowledge related to insufficient information (education about COPD).
- D. Social isolation related to insufficient personal resources (increased physical dependence).
Correct Answer: D
Rationale: The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Emotions frequently encountered include guilt, depression, anxiety, social isolation, denial, and dependence. Although deficient knowledge, hopelessness, and ineffective coping also may be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses.