Asthma (18 Questions)

1.1 At 9:30, Noémie Lessard, age 2½, was transferred from the emergency room to your unit following an episode of bronchospasm. This is the third time she has been admitted for the same type of problem. Upon admission, Noémie presents with moderate xiphoid, subcostal, and lower intercostal retractions and an occasional dry cough. Her vital signs are: P 96/min, regular; R 46/min, regular; T° (rectal) 37.7°C. When you auscultate the lungs, you hear wheezing in both pulmonary areas. Her oxygen saturation (SpO2) is 92% on room air. Her mother mentions that Noémie's sleep has been disturbed and that she has been more tired than usual over the past few days.

Question:
What clinical signs would indicate that a complication is imminent? Choose TWO (2) answers. *
1.2 Noémie weighs 12 kg. The doctor has prescribed the following:
*Prednisolone (Pediapred) 12 mg qd (corticosteroid)
*Salbutamol (Ventolin) 0.4 ml in 3 ml of normal saline q 2 h by nebulization
*Fluticasone (Flovent) 125 mcg, 3 puffs bid with a spacer and mask via nasal prongs at 1.5 L/min

Before she was hospitalized, Noémie wasn't taking any medication on a regular basis at home. Treatment was started as soon as the child arrived in the emergency room.

At 22:00, Noémie's mother says to you, "My daughter's breathing seems to have improved, but she is very restless and won't go to sleep. She's not usually like this."

Question:
Other than anxiety, what could explain the change in Noémie's behavior? *
1.3 Noémie will be discharged tomorrow. Her discharge prescription is as follows:
*Salbutamol (Ventolin) 100 mcg, 2 puffs every 4-6 hours
*Fluticasone (Flovent) 125 mcg, 2 puffs bid for 14 days, then discontinue completely *Prednisolone (Pediapred) 12 mg qd in the morning for 4 days

Question:
Which medication (inhaler) must the mother administer first when both medications (inhalers) have to be given during an asthma attack? *
1.4 Question:
What is the rationale for administering salbutamol (Ventolin) first? *
1.5 Noémie's mother says to you, "My daughter is much better. But is it really important that I give her the Flovent for as long as prescribed?"

Question:
What information will you give Noémie's mother to help her understand why it is important to continue the treatment as prescribed? *
2.1 Mr. Étienne Gagnon, a 52-year-old man with a history of asthma since childhood, is brought to the emergency department by his wife. She states that he started having difficulty breathing about an hour ago after working in the garage where he was exposed to dust and fumes. Upon arrival, Mr. Gagnon is in visible respiratory distress. He is sitting upright, using accessory muscles to breathe, and speaking in short sentences between breaths. He appears anxious and diaphoretic.

You quickly assess the following:
*Respiratory rate: 32 breaths/min, shallow
*Pulse: 116 beats/min, regular
*SpO₂: 88% on room air
*Audible wheezing on exhalation

No current medications administered

Question:
Which action should you take first? *
2.2 You auscultate Mr. Étienne Gagnon’s lungs and note widespread expiratory wheezing with diminished air entry at the bases. He appears fatigued and anxious, and is unable to complete full sentences. His oxygen saturation has dropped to 86% on room air, and he is using accessory muscles to breathe.

Medical Orders (standing orders):
*Administer salbutamol 2.5 mg via nebulizer q 20 minutes PRN for respiratory distress (max 3 doses).
*Increase oxygen as needed to maintain SpO₂ ≥ 92%.
*Notify physician if no improvement after 3 doses or condition worsens.

You administer the first dose of salbutamol 2.5 mg via nebulizer and increase oxygen to 4 L/min via nasal cannula. After 20 minutes, Mr. Gagnon reports slight relief, but he remains tachypneic and continues to use accessory muscles.

Question:
What will you do next? *
3. M. Jacques Tremblay, 24 years old, presents to the Emergency Department in respiratory distress. He is sitting in a tripod position, using accessory muscles to breathe. He can only speak in one-word sentences. Upon auscultation, the nurse hears audible wheezing throughout all lung fields.

Medical Orders:
*Oxygen to maintain SpO2 > 92%.
*Salbutamol (Ventolin) 5 mg via nebulizer STAT.
*Methylprednisolone (Solu-Medrol) 125 mg IV STAT.
*Chest X-ray.

Question:
Which intervention should the nurse implement first? *
4. Mme. Ginette Roy, 30 years old, was admitted for severe status asthmaticus. Upon admission, she had loud expiratory wheezing and a respiratory rate of 32. One hour later, the nurse assesses her and notes that the wheezing has stopped completely, but Mme. Roy appears drowsy, diaphoretic, and cyanotic around the lips. Respiratory rate is now 8 breaths/min.

Medical Orders:
*Continuous O2 saturation monitoring.
*Salbutamol nebulizers q20min PRN.
*Notify MD of changes in status.

Question:
How should the nurse interpret these findings? *
5. M. Pierre Gagnon, 55 years old, has a history of moderate persistent asthma. He is admitted for new-onset hypertension. The nurse reviews the new medication orders written by the resident physician.

Medical Orders:
*Low sodium diet.
*Propranolol 40 mg PO BID.
*Salbutamol Inhaler PRN.

Question:
What is the nurse’s priority action? *
6. Mme. Claire Bouchard, 40 years old, manages her asthma at home. She calls the clinic nurse because she has been coughing more frequently. She checked her Peak Expiratory Flow Rate (PEFR) and it is currently 65% of her personal best.

Medical Orders:
*Follow Asthma Action Plan.
-Green Zone: 80-100% (Maintenance).
-Yellow Zone: 50-80% (Caution).
-Red Zone: < 50% (Emergency).

Question:
Based on the Asthma Action Plan, what instruction should the nurse provide? *
7. M. Robert Fortin, 62 years old, is prescribed a Fluticasone (Flovent) inhaler for long-term asthma control. He complains to the nurse, "I hate taking this puffer; it leaves a bad taste and makes my tongue sore and white."

Medical Orders:
*Fluticasone 125 mcg MDI: 2 puffs BID.
*Salbutamol MDI: 2 puffs PRN.

Question:
What teaching should the nurse provide to prevent this complication? *
8. Mme. Sophie Lemieux, 22 years old, is having an asthma attack triggered by anxiety. She is receiving nebulizer treatment but continues to hyperventilate (RR 30) and says, "I can't get the air out!" She appears panicked.

Medical Orders:
*Salbutamol Nebulizer.
*Monitor SpO2.

Question:
Which nursing intervention can best assist her breathing mechanics? *
9. M. Sylvain Cote, 48 years old, is having acute shortness of breath. The nurse enters the room and sees M. Cote reaching for his Salmeterol (Serevent) inhaler.

Medical Orders:
*Salmeterol Diskus (LABA) BID.
*Salbutamol MDI (SABA) PRN.

Question:
What is the nurse’s priority action? *
10. Mme. Valérie Turcotte, 19 years old, is a university student who plays soccer. She tells the nurse, "I get wheezy and cough about 10 minutes after I start running, so I've stopped playing."

Medical Orders:
*Salbutamol MDI 2 puffs PRN.

Question:
What is the best recommendation for managing Exercise-Induced Asthma? *
11. M. Michel Desjardins, 35 years old, has allergic asthma triggered specifically by dust mites. He asks the nurse what changes he should make in his bedroom.

Medical Orders:
*Discharge home.
*Environmental control teaching.

Question:
Which instruction is most effective for controlling dust mites? *
12. Mme. Isabelle Lavoie, 28 years old, presents with a severe asthma exacerbation that is not responding to Salbutamol nebulizers and IV steroids. Her respiratory effort is increasing. The physician decides to escalate therapy.

Medical Orders:
*Magnesium Sulfate 2 g IV over 20 minutes.
*Continue Salbutamol q20min.

Question:
The patient asks, "I thought Magnesium was for leg cramps. Why are you giving it to me?" What is the nurse’s answer? *
13. M. André Lemieux, 45 years old, visits the pulmonary clinic due to a chronic cough and shortness of breath that worsens with exercise. The respirologist orders a Spirometry test to be performed today. M. Lemieux asks the nurse, "Why do I have to blow into this machine? Can't you just take an X-ray to see if I have asthma?"

Medical Orders:
*Full Pulmonary Function Tests (PFTs) including Spirometry.
*Pre- and Post-bronchodilator assessment.

Question:
What is the nurse’s best explanation regarding the purpose of the test? *