Question

A client who presented to the emergency department for an acute asthma attack has been receiving continuous albuterol nebulizers. However, the client reports dizziness. Assessment reveals respirations 30 breaths/minute, oxygen saturation of 88%, confusion, and absent breath sounds. What should the nurse do first?

Answer 1

Correct Answers:

Prepare equipment for intubation

Rationale :

🔶 The client is showing signs of impending respiratory failure, including confusion, absent breath sounds ("silent chest"), tachypnea (30 breaths/minute), and an oxygen saturation of 88%, despite continuous albuterol therapy.

🔶 Absent breath sounds in a client with a severe asthma attack are an ominous finding because they indicate minimal or no air movement, suggesting near-complete airway obstruction rather than improvement.

🔶 Confusion and dizziness are late manifestations of hypoxemia and hypercapnia, indicating that the brain is no longer receiving adequate oxygen and carbon dioxide is accumulating.

🔶 Using the ABC priority framework, airway and breathing take immediate precedence, making preparation for endotracheal intubation and mechanical ventilation the most urgent intervention.

🔶 Delaying advanced airway management places the client at risk for complete respiratory arrest, cardiac arrest, and death.

🔶 While preparing for intubation, the nurse should continue administering 100% oxygen, closely monitor vital signs, and assist the healthcare provider with emergency airway management.

🔶 Additional treatments such as systemic corticosteroids, magnesium sulfate, and continuous bronchodilator therapy may continue, but they should not delay securing the airway.

🔶 Preparing for intubation is the priority because the client has objective evidence of severe respiratory compromise and impending respiratory failure.

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Answer 2

Correct Answers:

SpO2 of 82% on room air

Rationale :

🔷 An oxygen saturation (SpO₂) of 82% indicates severe hypoxemia, meaning the body's tissues are not receiving enough oxygen to meet metabolic demands.

🔷 Pneumonia causes inflammation and alveolar consolidation, where the air sacs become filled with fluid, pus, and inflammatory cells, significantly impairing gas exchange.

🔷 An SpO₂ below 90% is considered abnormal, and a value of 82% is a medical emergency that requires immediate intervention to prevent respiratory failure.

🔷 Using the ABC priority framework, impaired breathing and oxygenation take precedence over all other assessment findings because inadequate oxygen delivery can rapidly lead to organ dysfunction.

🔷 The nurse should immediately administer supplemental oxygen, position the client in High Fowler's position, reassess respiratory status, and notify the healthcare provider.

🔷 Continuous monitoring of oxygen saturation, breath sounds, respiratory effort, and mental status is essential to evaluate the client's response to treatment.

🔷 If hypoxemia persists despite oxygen therapy, the client may require advanced respiratory support, such as high-flow oxygen, noninvasive ventilation, or endotracheal intubation.

🔷 An SpO₂ of 82% is the highest-priority finding because severe hypoxemia can rapidly progress to respiratory failure and requires immediate intervention.

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Answer 3

Correct Answers:

Begin nebulized albuterol.

Rationale :

🟢 The client is experiencing an acute asthma exacerbation, as evidenced by difficulty breathing, chest tightness, difficulty speaking, oxygen saturation of 91%, and bilateral expiratory wheezes.

🟢 During an asthma attack, bronchospasm causes narrowing of the airways, making it difficult for air to move in and out of the lungs and resulting in impaired oxygenation.

🟢 Nebulized albuterol is a short-acting beta₂-adrenergic agonist (SABA) that rapidly relaxes bronchial smooth muscle, producing bronchodilation and improving airflow within minutes.

🟢 Using the ABC (Airway, Breathing, Circulation) priority framework, improving the client's breathing by relieving bronchospasm is the most urgent intervention.

🟢 Early administration of albuterol helps improve oxygenation, decrease the work of breathing, and reduce the risk of progression to status asthmaticus or respiratory failure.

🟢 The nurse should continue to monitor oxygen saturation, respiratory rate, breath sounds, peak expiratory flow (if possible), and the client's response to treatment.

🟢 Additional therapies such as supplemental oxygen, systemic corticosteroids, and magnesium sulfate may be required if symptoms persist, but they do not act as rapidly as albuterol.

🟢 Nebulized albuterol is the priority intervention because it provides the fastest reversal of bronchospasm and improves airway patency during an acute asthma attack.

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Answer 4

Correct Answers

Constricts vessels and reduces swelling but must be used cautiously with hypertensive clients [ Phenylephrine ]
Long term use to prevent respiratory symptoms by decreasing response to irritants and triggers [ Montelukast ]
Given first in clients experiencing dyspnea, wheezing, and hypoxia to decrease symptoms [ Albuterol ]
Thins secretions in clients who have lower respiratory infections and COPD exacerbations [ Guaifenesin ]
Secondary treatment in acute asthma or COPD exacerbations to enhance bronchodilation [ Ipratropium (Atrovent) ]

Rationale :

🌡️ Phenylephrine

✅ Constricts vessels and reduces swelling but must be used cautiously with hypertensive clients

🔶 Phenylephrine is an alpha₁-adrenergic agonist that causes vasoconstriction, reducing swelling of the nasal mucosa.

🔶 It is commonly used as a nasal decongestant to relieve nasal congestion caused by colds or allergic rhinitis.

🔶 Because it constricts blood vessels throughout the body, it can increase blood pressure.

🔶 Clients with hypertension, coronary artery disease, or hyperthyroidism should use this medication cautiously.

🔶 The nurse should advise clients not to exceed the recommended dose because excessive use can cause rebound nasal congestion (with nasal spray formulations).

🔶 Blood pressure and heart rate should be monitored in clients with cardiovascular disease.

🔶 Phenylephrine should be used only as directed and for the recommended duration.

🔶 Its primary action is vasoconstriction, making it effective for reducing nasal swelling but requiring caution in hypertensive clients.

🌿 Montelukast

✅ Long-term use to prevent respiratory symptoms by decreasing response to irritants and triggers

🔹 Montelukast is a leukotriene receptor antagonist used for long-term control of asthma and allergic rhinitis.

🔹 It blocks leukotrienes, inflammatory chemicals that contribute to bronchoconstriction, mucus production, and airway inflammation.

🔹 It helps prevent symptoms triggered by exercise, allergens, cold air, and environmental irritants.

🔹 Montelukast is not effective for acute asthma attacks and should never replace a rescue inhaler.

🔹 The medication is taken daily, even when the client is symptom-free.

🔹 Clients should continue carrying a short-acting bronchodilator for emergencies.

🔹 Nurses should monitor for rare neuropsychiatric effects, including mood changes or suicidal thoughts.

🔹 Montelukast is used for prevention, not immediate relief, making it ideal for long-term asthma control.

🌬️ Albuterol

✅ Given first in clients experiencing dyspnea, wheezing, and hypoxia to decrease symptoms

🟢 Albuterol is a short-acting beta₂-adrenergic agonist (SABA) and is the first-line rescue medication for acute bronchospasm.

🟢 It rapidly relaxes bronchial smooth muscle, producing bronchodilation within minutes.

🟢 It is indicated for clients experiencing acute dyspnea, wheezing, chest tightness, and hypoxia due to asthma or COPD exacerbations.

🟢 The medication improves airflow, decreases the work of breathing, and increases oxygenation.

🟢 Common adverse effects include tachycardia, tremors, nervousness, and palpitations.

🟢 The nurse should assess lung sounds, oxygen saturation, respiratory rate, and symptom improvement after administration.

🟢 If symptoms do not improve after repeated doses, additional emergency treatment may be required.

🟢 Albuterol is the first medication administered during acute bronchospasm because it provides rapid bronchodilation.

💦 Guaifenesin

✅ Thins secretions in clients who have lower respiratory infections and COPD exacerbations

🔵 Guaifenesin is an expectorant that reduces the thickness and stickiness of respiratory secretions.

🔵 It works by increasing the water content of mucus, making secretions easier to cough up.

🔵 It is commonly used in clients with bronchitis, pneumonia, COPD exacerbations, and other lower respiratory tract infections.

🔵 Adequate fluid intake enhances the effectiveness of guaifenesin by helping loosen mucus.

🔵 The medication improves airway clearance but does not relieve bronchospasm.

🔵 Nurses should encourage coughing and deep breathing exercises to facilitate mucus removal.

🔵 Clients should notify the healthcare provider if the cough persists or is accompanied by high fever or bloody sputum.

🔵 Guaifenesin promotes mucus clearance by thinning respiratory secretions.

🌪️ Ipratropium (Atrovent)

✅ Secondary treatment in acute asthma or COPD exacerbations to enhance bronchodilation

🟣 Ipratropium is a short-acting anticholinergic bronchodilator that blocks muscarinic receptors in the airways.

🟣 This action relaxes bronchial smooth muscle and decreases bronchoconstriction.

🟣 During acute asthma or COPD exacerbations, ipratropium is commonly given in combination with albuterol to provide greater bronchodilation.

🟣 It is considered a secondary treatment because its onset is slower than albuterol.

🟣 Ipratropium is especially beneficial during moderate to severe asthma attacks and COPD exacerbations.

🟣 Common adverse effects include dry mouth, throat irritation, and a bitter taste.

🟣 The nurse should assess breath sounds, oxygen saturation, and respiratory effort after treatment.

🟣 Ipratropium enhances bronchodilation when used alongside albuterol during acute respiratory exacerbations.

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Answer 5

Correct Answers:

Apply oxygen via nasal cannula at 2 L/min

Rationale :

🔷 The client is showing signs of acute respiratory distress, including shortness of breath, tachypnea (32 breaths/min), use of accessory muscles, and decreased oxygen saturation, indicating impaired oxygenation.

🔷 Using the ABC (Airway, Breathing, Circulation) priority framework, the nurse should first improve oxygenation because hypoxemia can rapidly progress to respiratory failure if left untreated.

🔷 Clients with COPD should receive low-flow oxygen (usually 1–2 L/min via nasal cannula) to increase oxygen saturation while minimizing the risk of suppressing the respiratory drive in those with chronic CO₂ retention.

🔷 The target oxygen saturation for many COPD clients is 88%–92%, which provides adequate oxygenation without causing excessive oxygen administration.

🔷 After oxygen is initiated, the nurse should reassess the client's respiratory status, oxygen saturation, work of breathing, and response to therapy.

🔷 Additional prescribed treatments, such as nebulized bronchodilators (albuterol), corticosteroids, and further diagnostic evaluation, are important but should follow the immediate correction of hypoxemia.

🔷 Continuous monitoring is essential because worsening respiratory distress may require escalation to noninvasive ventilation or endotracheal intubation if oxygenation does not improve.

🔷 Applying low-flow oxygen is the priority because correcting hypoxemia is the most immediate life-saving intervention in a client with COPD and respiratory distress.

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Answer 6

Correct Answers

Encourage pursed-lip breathing [ Indicated ]
Titrate oxygen to maximum of BL via nasal cannula [ contraindicated ]
Teach the client about increasing oral fluids [ Indicated ]
Place the client in lateral position [ contraindicated ]
Encourage strict bed rest to conserve energy [ contraindicated ]
Request small, frequent meals from dietary [ Indicated ]

Rationale :

✅ Encourage pursed-lip breathing

🌬️ Indicated

🔹 Pursed-lip breathing helps keep the airways open longer during exhalation by creating positive airway pressure.

🔹 It reduces air trapping, improves ventilation, and decreases the work of breathing.

🔹 This technique also helps relieve dyspnea and promotes more complete emptying of the lungs.

🔹 Clients are instructed to inhale through the nose and exhale slowly through pursed lips, taking twice as long to exhale as to inhale.

🔹 It is especially beneficial during episodes of shortness of breath or physical activity.

🔹 Regular practice improves breathing efficiency and reduces anxiety associated with dyspnea.

🔹 Nurses should demonstrate the technique and observe return demonstration.

🔹 Pursed-lip breathing is an effective non-pharmacologic intervention for clients with chronic bronchitis and COPD.

❌ Titrate oxygen to maximum of 8 L via nasal cannula

🫁 Contraindicated

🔸 Clients with chronic bronchitis often have chronic CO₂ retention and require carefully controlled low-flow oxygen therapy.

🔸 Administering 8 L/min via nasal cannula may lead to excessive oxygen delivery, worsening hypercapnia in susceptible clients.

🔸 Oxygen should be titrated to maintain a target SpO₂ of approximately 88%–92%, unless otherwise prescribed.

🔸 Nurses should closely monitor oxygen saturation and the client's respiratory status.

🔸 Oxygen is a medication and should be administered at the lowest effective dose.

🔸 Excessive oxygen may reduce the client's respiratory drive in some cases.

🔸 Low-flow oxygen is generally initiated first and adjusted according to the client's response.

🔸 High-flow oxygen via nasal cannula without indication is contraindicated because it may worsen CO₂ retention.

✅ Teach the client about increasing oral fluids

💧 Indicated

🔹 Adequate hydration helps thin bronchial secretions, making mucus easier to expectorate.

🔹 Thin secretions improve airway clearance and reduce airway obstruction.

🔹 Unless contraindicated by conditions such as heart failure or renal disease, clients should be encouraged to increase fluid intake.

🔹 Warm fluids may also soothe irritated airways and assist mucus mobilization.

🔹 Hydration works together with coughing and breathing exercises to improve secretion clearance.

🔹 Nurses should monitor intake, output, and hydration status.

🔹 Encourage water throughout the day rather than consuming large amounts at once.

🔹 Increasing oral fluids promotes mucus clearance and improves respiratory function.

❌ Place the client in lateral position

🛏️ Contraindicated

🔸 Clients with dyspnea breathe more effectively when positioned in High Fowler's or tripod position.

🔸 A lateral position may limit chest expansion and make breathing more difficult.

🔸 Upright positioning allows the diaphragm to descend more effectively.

🔸 High Fowler's also reduces pressure on the lungs and improves ventilation.

🔸 Position changes should always promote optimal lung expansion.

🔸 Clients experiencing respiratory distress should remain as upright as tolerated.

🔸 Frequent repositioning is beneficial, but lateral positioning is not preferred for acute dyspnea.

🔸 The lateral position is contraindicated because it does not optimize lung expansion in a dyspneic client.

❌ Encourage strict bed rest to conserve energy

🚶 Contraindicated

🔸 Although rest periods are important, strict bed rest promotes secretion retention and increases the risk of complications such as atelectasis and venous thromboembolism.

🔸 Clients should instead balance activity with adequate rest according to their tolerance.

🔸 Early ambulation and light activity help improve ventilation and mobilize secretions.

🔸 Energy conservation techniques should be taught without completely restricting mobility.

🔸 Pulmonary rehabilitation encourages gradual physical activity.

🔸 Nurses should schedule activities to allow adequate recovery between tasks.

🔸 Activity should be stopped if severe dyspnea develops.

🔸 Strict bed rest is contraindicated because controlled activity promotes better respiratory function than complete immobility.

✅ Request small, frequent meals from dietary

🍽️ Indicated

🔹 Large meals increase abdominal pressure against the diaphragm, making breathing more difficult.

🔹 Small, frequent meals reduce fatigue during eating and decrease oxygen demand.

🔹 Clients with chronic bronchitis often become short of breath while eating, so smaller meals are better tolerated.

🔹 High-calorie, high-protein foods help maintain body weight and respiratory muscle strength.

🔹 Meals should be eaten slowly with rest periods as needed.

🔹 Bronchodilators may be administered before meals if prescribed to improve comfort while eating.

🔹 Nutritional support helps prevent malnutrition, which is common in advanced COPD.

🔹 Small, frequent meals improve nutritional intake while minimizing dyspnea during eating.

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Answer 7

Correct Answers

Chronic, productive cough for more than 3 months in two consecutive years [ COPD ]
Wheezing and chest tightness triggered by seasonal allergies or exercise [ Asthma ]
Rapid onset of purulent sputum, fever, and chills [ Pneumonia ]
Barrel chest and prolonged expiratory phase [ COPD ]
Acute airway obstruction reversed with bronchodilators [ Asthma ]
Crackles in the lungs, dullness to percussion, and decreased breath sounds in one lobe [ Pneumonia ]

Rationale :

🚬 Chronic, productive cough for more than 3 months in two consecutive years — COPD

🔸 A chronic productive cough lasting at least 3 months for 2 consecutive years is the diagnostic hallmark of chronic bronchitis, a subtype of COPD.

🔸 Long-term exposure to cigarette smoke or other lung irritants causes chronic inflammation of the bronchi and excessive mucus production.

🔸 Hypersecretion of mucus leads to airway obstruction and persistent coughing.

🔸 Clients commonly report daily sputum production that gradually worsens over time.

🔸 Airflow limitation in COPD is progressive and not fully reversible.

🔸 Smoking cessation is the most effective intervention for slowing disease progression.

🔸 Nurses should encourage pulmonary rehabilitation, vaccinations, and adherence to bronchodilator therapy.

🔸 A chronic productive cough meeting the "3 months for 2 years" criterion is characteristic of COPD.

🌼 Wheezing and chest tightness triggered by seasonal allergies or exercise — Asthma

🟢 Asthma is characterized by airway hyperresponsiveness triggered by allergens, exercise, cold air, respiratory infections, or irritants.

🟢 Exposure to triggers causes bronchospasm, airway inflammation, and increased mucus production.

🟢 Common symptoms include wheezing, chest tightness, coughing, and shortness of breath.

🟢 Symptoms are usually episodic and vary in severity.

🟢 Clients often have a history of allergic conditions such as allergic rhinitis or eczema.

🟢 Avoiding triggers and using prescribed controller medications reduce exacerbations.

🟢 Rescue inhalers provide rapid relief during acute bronchospasm.

🟢 Exercise- or allergy-induced wheezing is a classic feature of asthma.

🤒 Rapid onset of purulent sputum, fever, and chills — Pneumonia

🔵 Pneumonia is an acute infection of the lung parenchyma caused by bacteria, viruses, or fungi.

🔵 Clients often develop symptoms suddenly, including fever, chills, productive cough with purulent sputum, pleuritic chest pain, and malaise.

🔵 Infection causes inflammatory fluid to fill the alveoli, impairing gas exchange.

🔵 Purulent sputum indicates the presence of infection and inflammatory cells.

🔵 Prompt antibiotic therapy is essential for bacterial pneumonia.

🔵 Oxygen therapy and adequate hydration support recovery.

🔵 Nurses should monitor respiratory status closely for worsening hypoxemia.

🔵 The combination of fever, chills, and purulent sputum strongly indicates pneumonia.

🫁 Barrel chest and prolonged expiratory phase — COPD

🟠 A barrel chest develops because of chronic air trapping and lung hyperinflation, particularly in emphysema.

🟠 Destruction of alveolar walls decreases elastic recoil, making expiration difficult.

🟠 Clients compensate by taking longer to exhale, producing a prolonged expiratory phase.

🟠 Accessory muscle use and pursed-lip breathing are also common.

🟠 Hyperinflation gradually changes the shape of the thorax.

🟠 These findings indicate advanced airflow limitation.

🟠 Smoking is the leading cause of emphysema.

🟠 Barrel chest with prolonged expiration is characteristic of COPD.

💨 Acute airway obstruction reversed with bronchodilators — Asthma

🟣 Asthma causes reversible bronchoconstriction, distinguishing it from COPD.

🟣 Short-acting bronchodilators such as albuterol rapidly relax bronchial smooth muscle.

🟣 Symptoms improve significantly after bronchodilator administration.

🟣 Reversibility of airflow obstruction is a key diagnostic feature of asthma.

🟣 Airway inflammation may also require corticosteroid therapy.

🟣 Clients should have an individualized asthma action plan.

🟣 Peak flow monitoring helps assess disease control.

🟣 Reversible airway obstruction following bronchodilator therapy is the hallmark of asthma.

🩺 Crackles, dullness to percussion, and decreased breath sounds in one lobe — Pneumonia

🟤 Pneumonia causes consolidation of lung tissue as alveoli fill with fluid and inflammatory exudate.

🟤 Consolidated lung tissue produces crackles during inspiration.

🟤 Dullness to percussion occurs because fluid-filled lung tissue transmits sound differently than air-filled lung.

🟤 Breath sounds become decreased over the affected lobe due to impaired air movement.

🟤 The condition may also produce increased tactile fremitus and bronchial breath sounds.

🟤 Chest X-ray commonly demonstrates lobar infiltrates or consolidation.

🟤 Appropriate antimicrobial therapy and supportive care promote recovery.

🟤 Localized crackles, dull percussion, and decreased breath sounds are classic findings of lobar pneumonia.

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Answer 8

Correct Answers:

Document the findings and continue monitoring

Rationale :

🔹 The ABG results show respiratory acidosis with partial metabolic compensation: pH 7.33 (slightly low), PaCO₂ 55 mm Hg (elevated), and HCO₃⁻ 28 mEq/L (slightly elevated).

🔹 These findings are common in clients with chronic COPD, who often retain carbon dioxide because of long-term airflow obstruction and impaired alveolar ventilation.

🔹 The client's PaO₂ of 68 mm Hg indicates mild hypoxemia, but this is acceptable for many stable COPD clients receiving low-flow oxygen, whose target oxygen saturation is generally 88%–92%.

🔹 Most importantly, the client is alert and oriented ×4, indicating there are no signs of acute neurological deterioration or impending respiratory failure.

🔹 The nurse should continue the prescribed 2 L/min oxygen, monitor respiratory status, assess for changes in mental status, and repeat ABGs if the client's condition worsens.

🔹 Increasing oxygen unnecessarily in a stable COPD client may worsen carbon dioxide retention in susceptible individuals, so oxygen should be titrated carefully.

🔹 The nurse should continue monitoring respiratory rate, breath sounds, oxygen saturation, work of breathing, and level of consciousness to detect any signs of deterioration.

🔹 Because the client is clinically stable and the ABGs are consistent with chronic compensated COPD, the appropriate action is to document the findings and continue monitoring.

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Answer 9

Correct Answers:

Silent breath sounds

Rationale :

🔶 Silent breath sounds ("silent chest") are one of the most dangerous findings in a client with an acute asthma exacerbation because they indicate little or no air movement through the airways.

🔶 In severe asthma, intense bronchospasm, airway inflammation, and mucus plugging can become so pronounced that airflow is nearly absent, causing wheezing to disappear.

🔶 Although wheezing is a common sign of asthma, the absence of breath sounds is not an improvement—it is a sign of critical airway obstruction and impending respiratory failure.

🔶 A client with silent breath sounds is at high risk for hypoxemia, hypercapnia, respiratory arrest, and cardiac arrest if immediate treatment is not provided.

🔶 The nurse should immediately assess the airway, administer high-flow oxygen, prepare for advanced airway management, and anticipate treatments such as continuous nebulized bronchodilators, IV corticosteroids, magnesium sulfate, and possible endotracheal intubation.

🔶 Continuous monitoring of oxygen saturation, respiratory effort, breath sounds, mental status, and arterial blood gases (ABGs) is essential because the client's condition can deteriorate rapidly.

🔶 Using the ABC (Airway, Breathing, Circulation) priority framework, restoring airway patency and ensuring adequate ventilation are the highest priorities.

🔶 Silent breath sounds indicate that airflow has become critically reduced, making this the clearest sign that the client's asthma is worsening and requires immediate intervention.

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Answer 10

Correct Answers:

Obtain both sputum & blood cultures.

Rationale :

🔵 Azithromycin is a broad-spectrum macrolide antibiotic used to treat bacterial pneumonia by inhibiting bacterial protein synthesis.

🔵 Before administering the first dose of an antibiotic, the nurse should obtain both sputum and blood cultures whenever possible to identify the causative microorganism.

🔵 Collecting cultures before antibiotic therapy increases the likelihood of accurately isolating the pathogen because antibiotics can suppress bacterial growth and lead to false-negative culture results.

🔵 Identifying the infecting organism allows the healthcare provider to tailor antibiotic therapy based on culture and sensitivity results, improving treatment effectiveness.

🔵 Obtaining cultures should not significantly delay antibiotic administration; once the specimens are collected, the prescribed antibiotic should be started promptly.

🔵 Early administration of appropriate antibiotics is associated with reduced morbidity, shorter hospital stays, and lower mortality in clients with bacterial pneumonia.

🔵 The nurse should also assess allergies, monitor vital signs, evaluate respiratory status, and observe for therapeutic response and adverse drug reactions during treatment.

🔵 Obtaining sputum and blood cultures before the first antibiotic dose is the priority because it provides the most accurate identification of the infecting organism while preserving the effectiveness of subsequent antimicrobial therapy.

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Nursing Action	Indicated	contraindicated
Encourage pursed-lip breathing
Titrate oxygen to maximum of BL via nasal cannula
Teach the client about increasing oral fluids
Place the client in lateral position
Encourage strict bed rest to conserve energy
Request small, frequent meals from dietary

	COPD	Asthma	Pneumonia
Chronic, productive cough for more than 3 months in two consecutive years
Wheezing and chest tightness triggered by seasonal allergies or exercise
Rapid onset of purulent sputum, fever, and chills
Barrel chest and prolonged expiratory phase
Acute airway obstruction reversed with bronchodilators
Crackles in the lungs, dullness to percussion, and decreased breath sounds in one lobe

NR324 Quiz 2

No.

2 :
A client admitted with left lower lobe pneumonia reports productive cough with green sputum and increased fatigue. Which assessment finding requires immediate nursing intervention?

3 :
A 24-year-old client with moderate persistent asthma arrives in the emergency department with difficulty breathing, chest tightness, and difficulty speaking. Oxygen saturation is 91% on room air and expiratory heard bilaterally. What is the priority nursing intervention?

4 :
An assessment was made

Correct Answers

6 :
The nurse is caring for a client with chronic bronchitis admitted for dyspnea.

Correct Answers

7 :
Classify each clinical finding with the correct condition below. Only one answer per row.

Correct Answers

8 :
A nurse cares for a client with COPD and reviews arterial blood gas (ABG) results: pH 7.33, PaCO: 55 mm Hg, HCO, 28 mEq/L, PaO: 68 mm Hg. The client is receiving 2 L/min of oxygen via nasal cannula and is alert an oriented x4. Which nursing action is appropriate?

9 :
A client with asthma reports dyspnea, a frequent cough, and wheezing after using the rescue inhaler at home. The client is using accessory muscles, respiratory rate is 30, and an SpO: is 93% on room air. Which finding indicates the client's condition is worsening?

10 :
A client with pneumonia is admitted to the medical surgical unit. The client has azithromycin 500mg IV ordered daily. What is the nurse's priority intervention before administration?

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	Phenylephrine	Montelukast	Albuterol	Guaifenesin	Ipratropium (Atrovent)
Constricts vessels and reduces swelling but must be used cautiously with hypertensive clients
Long term use to prevent respiratory symptoms by decreasing response to irritants and triggers
Given first in clients experiencing dyspnea, wheezing, and hypoxia to decrease symptoms
Thins secretions in clients who have lower respiratory infections and COPD exacerbations
Secondary treatment in acute asthma or COPD exacerbations to enhance bronchodilation

NR324 Quiz 2

No.

2 : A client admitted with left lower lobe pneumonia reports productive cough with green sputum and increased fatigue. Which assessment finding requires immediate nursing intervention?

3 : A 24-year-old client with moderate persistent asthma arrives in the emergency department with difficulty breathing, chest tightness, and difficulty speaking. Oxygen saturation is 91% on room air and expiratory heard bilaterally. What is the priority nursing intervention?

4 : An assessment was made

Correct Answers

6 : The nurse is caring for a client with chronic bronchitis admitted for dyspnea.

Correct Answers

7 : Classify each clinical finding with the correct condition below. Only one answer per row.

Correct Answers

8 : A nurse cares for a client with COPD and reviews arterial blood gas (ABG) results: pH 7.33, PaCO: 55 mm Hg, HCO, 28 mEq/L, PaO: 68 mm Hg. The client is receiving 2 L/min of oxygen via nasal cannula and is alert an oriented x4. Which nursing action is appropriate?

9 : A client with asthma reports dyspnea, a frequent cough, and wheezing after using the rescue inhaler at home. The client is using accessory muscles, respiratory rate is 30, and an SpO: is 93% on room air. Which finding indicates the client's condition is worsening?

10 : A client with pneumonia is admitted to the medical surgical unit. The client has azithromycin 500mg IV ordered daily. What is the nurse's priority intervention before administration?

2 :
A client admitted with left lower lobe pneumonia reports productive cough with green sputum and increased fatigue. Which assessment finding requires immediate nursing intervention?

3 :
A 24-year-old client with moderate persistent asthma arrives in the emergency department with difficulty breathing, chest tightness, and difficulty speaking. Oxygen saturation is 91% on room air and expiratory heard bilaterally. What is the priority nursing intervention?

4 :
An assessment was made

6 :
The nurse is caring for a client with chronic bronchitis admitted for dyspnea.

7 :
Classify each clinical finding with the correct condition below. Only one answer per row.

8 :
A nurse cares for a client with COPD and reviews arterial blood gas (ABG) results: pH 7.33, PaCO: 55 mm Hg, HCO, 28 mEq/L, PaO: 68 mm Hg. The client is receiving 2 L/min of oxygen via nasal cannula and is alert an oriented x4. Which nursing action is appropriate?

9 :
A client with asthma reports dyspnea, a frequent cough, and wheezing after using the rescue inhaler at home. The client is using accessory muscles, respiratory rate is 30, and an SpO: is 93% on room air. Which finding indicates the client's condition is worsening?

10 :
A client with pneumonia is admitted to the medical surgical unit. The client has azithromycin 500mg IV ordered daily. What is the nurse's priority intervention before administration?