Medical Surgical Asthma #5

Question

The nurse’s asthmatic client is experiencing an ineffective breathing pattern as evidenced by dyspnea, tachypnea, wheezing, and use of accessory muscles. Which assessment finding and intervention is best indicated with this nursing diagnosis?

Answers

  1. Keep the head of the bed flat.
    • Rationale:

      This answer is not correct because it does not allow for adequate lung expansion. Raising the head of the bed permits diaphragm excursion and sufficient lung expansion.

  2. Assess for cough effectiveness and productivity.
    • Rationale:

      This answer is not correct because the client is not coughing. This is assessed when a client is at risk for ineffective airway clearance. Coughing helps remove secretions.

  3. Perform chest percussion.
    • Rationale:

      This answer is not correct because chest percussion is used to break up thick secretions in the lungs so secretions can be easily removed. This client shows no evidence of a productive cough. It is performed with cupped hands in a rhythmic fashion. It is also called chest physiotherapy.

  4. Monitor arterial blood gases.
    • Rationale:

      This answer is correct because during an asthma attack, clients can develop an acid-base imbalance. Monitoring the ABGs will allow for quick intervention if the client is in respiratory alkalosis. If the ABGs show respiratory acidosis, that indicates pending respiratory failure.

Overview

Clients with asthma are at risk for ineffective breathing patterns as evidenced by dyspnea, tachypnea, cough, nasal flare, wheezing, and accessory muscle use. Interventions include proper respiratory assessments, monitoring of oxygen saturation, and ABGs.

Explanation

Learning Outcomes

Clients with asthma are at risk for ineffective breathing patterns as evidenced by dyspnea, tachypnea, cough, nasal flare, wheezing, and accessory muscle use. Interventions include proper respiratory assessments, monitoring of oxygen saturation and ABGs. Monitoring the ABGs will allow for quick intervention if the client is in respiratory alkalosis. If the ABGs show respiratory acidosis, that indicates pending respiratory failure. Raising the head of the bed promotes lung expansion and diaphragm excursion. Chest percussion and assessing cough productivity is indicated in clients with ineffective airway clearance. This is due to excessive mucus production, bronchospasm, or fatigue.

Test Taking Tip

Know the differences between nursing diagnoses and their specific interventions.

Video Rationale