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 :

💁‍♂️Absent breath sounds during a severe asthma attack indicate critically reduced airflow, sometimes described as a silent chest.

🚨Confusion, an SpO₂ of 88%, and severe tachypnea indicate worsening hypoxemia and impending respiratory failure.

⚠️Continuous albuterol has failed to restore adequate ventilation, so additional rescue inhaler therapy is unlikely to stabilize the client.

🩺The priority is preparation for endotracheal intubation and mechanical ventilation to establish a patent airway and support gas exchange.

📌Core Message

Silent breath sounds, severe hypoxemia, and altered mental status during asthma indicate impending respiratory failure requiring immediate airway support.

Answer 2

Correct Answers:

SpO₂ of 82% on room air

Rationale :

💁‍♂️An SpO₂ of 82% indicates severe hypoxemia requiring immediate oxygenation support.

🚑Using the ABC priority framework, impaired breathing and oxygenation take precedence over fever or laboratory abnormalities.

🌡️A temperature of 100.8°F is consistent with pneumonia and is not independently the most urgent finding.

🩺The nurse should promptly address the client's oxygenation status to prevent tissue hypoxia and respiratory deterioration.

📌Core Message

Severe oxygen desaturation in pneumonia requires immediate intervention because inadequate oxygenation threatens vital organs.

Answer 3

Correct Answers:

Begin nebulized albuterol.

Rationale :

💨Albuterol is a short-acting beta₂-adrenergic agonist that rapidly produces bronchodilation during an acute asthma exacerbation.

😣Difficulty speaking, chest tightness, wheezing, and an SpO₂ of 91% indicate significant airway obstruction.

⚡A rapidly acting bronchodilator is therefore the priority medication for improving airflow.

💉IV methylprednisolone reduces airway inflammation but has a slower onset and does not replace immediate bronchodilation.

📌Core Message

Acute asthma with significant bronchospasm requires rapid treatment with a short-acting bronchodilator.

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 produces alpha₁-mediated vasoconstriction that decreases nasal mucosal swelling but can increase blood pressure.

🍃Montelukast blocks leukotriene receptors and is used for long-term asthma prevention, not acute attacks.

💨Albuterol rapidly activates beta₂ receptors to produce bronchodilation during acute bronchospasm.

💧Guaifenesin acts as an expectorant, while ipratropium provides anticholinergic bronchodilation as adjunctive therapy.

📌Core Message

Respiratory medications differ by mechanism, with some providing acute bronchodilation while others control inflammation, congestion, or secretions.

Answer 5

Correct Answers:

Administer albuterol via nebulizer as prescribed

Rationale :

💨The client has evidence of significant bronchospasm and respiratory distress, including tachypnea and accessory muscle use.

🤙Because the client is already sitting upright, repositioning to high-Fowler's provides little additional immediate benefit.

⚡Nebulized albuterol rapidly relaxes bronchial smooth muscle and improves airflow during a COPD exacerbation.

💉IV corticosteroids are also appropriate but have a slower therapeutic onset than inhaled bronchodilation.

📌Core Message

Acute COPD respiratory distress with bronchospasm requires prompt short-acting bronchodilator therapy when positioning is already optimized.

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 :

🌬️Pursed-lip breathing prolongs expiration and helps prevent premature airway collapse in chronic bronchitis and COPD.

💧Adequate hydration helps thin respiratory secretions, while small frequent meals reduce the work associated with eating and breathing.

🔴Oxygen should be titrated to the prescribed saturation target, commonly around 88%–92% in clients at risk for chronic hypercapnia, rather than automatically increased to a maximum flow.

🚶Appropriate activity and positioning promote ventilation and conditioning, whereas strict bed rest and lateral positioning are generally not preferred for dyspnea management.

📌Core Message

Chronic bronchitis management emphasizes controlled breathing, appropriate oxygen titration, hydration, nutrition, and preservation of activity tolerance.

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 bronchitis, a COPD phenotype, is clinically associated with a persistent productive cough occurring for at least three months in two consecutive years.

🌸Asthma produces variable and reversible airway obstruction that is often triggered by allergens, exercise, or environmental exposures.

🦠Pneumonia commonly causes acute fever, chills, purulent sputum, crackles, and localized consolidation findings.

📦A barrel chest and prolonged expiration reflect chronic airflow trapping characteristic of COPD.

📌Core Message

COPD produces chronic airflow limitation, asthma produces reversible bronchospasm, and pneumonia produces acute infectious consolidation.

Answer 8

Correct Answers:

Document the findings and continue monitoring

Rationale :

🧪A pH of 7.33, PaCO₂ of 55 mm Hg, and HCO₃⁻ of 28 mEq/L indicate partially compensated respiratory acidosis, which may occur in chronic COPD.

👉A PaO₂ of 68 mm Hg represents mild hypoxemia but can be compatible with the client's chronic respiratory baseline.

🧠The client is alert and oriented, showing no evidence of acute neurologic deterioration from worsening hypercapnia.

📋Because the client is clinically stable on 2 L/min oxygen, continued monitoring is appropriate rather than aggressively increasing oxygen delivery.

📌Core Message

Stable COPD may demonstrate compensated carbon dioxide retention, so treatment should be guided by the client's overall clinical status.

Answer 9

Correct Answers:

Silent breath sounds

Rationale :

🔇A silent chest means airflow has become so severely restricted that wheezing can no longer be produced.

🚨This finding indicates extreme airway obstruction and possible impending respiratory failure.

💁‍♂️Wheezing may actually decrease as asthma worsens when insufficient air moves through the bronchi.

⚡Immediate escalation of airway and respiratory support is therefore required.

📌Core Message

A silent chest during an asthma exacerbation signals critically reduced airflow and impending respiratory failure.

Answer 10

Correct Answers:

Obtain both sputum & blood cultures.

Rationale :

🧫Cultures should ideally be obtained before the first dose of an antibiotic whenever ordered and clinically feasible.

💊Administering azithromycin before collecting cultures can decrease bacterial recovery and reduce diagnostic accuracy.

🦠Blood and sputum specimens help identify the causative organism and guide later antimicrobial therapy.

⏱️After appropriate specimens are obtained, the prescribed antibiotic should be administered promptly without unnecessary delay.

📌Core Message

Obtain ordered cultures before antibiotics whenever possible so the causative organism can be accurately identified.

Indication	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

Actions	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

Finding	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

📌Core Message

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?

📌Core Message

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?

📌Core Message

4 :
A nurse is caring for a client.

Correct Answers

📌Core Message

📌Core Message

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

Correct Answers

📌Core Message

7 :
A nurse is caring for a client.

Correct Answers

📌Core Message

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?

📌Core Message

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?

📌Core Message

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?

📌Core Message

📌Core Message

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?

📌Core Message

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?

📌Core Message

4 : A nurse is caring for a client.

Correct Answers

📌Core Message

📌Core Message

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

Correct Answers

📌Core Message

7 : A nurse is caring for a client.

Correct Answers

📌Core Message

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?

📌Core Message

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?

📌Core Message

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?

📌Core Message

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 :
A nurse is caring for a client.

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

7 :
A nurse is caring for a client.

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?