Answer to Question 1
D
Feedback:
The nurse would assess breath sounds because ipratropium is indicated for treatment of bronchospasm so it is important to get a baseline assessment to determine whether the drug improves the patient's condition after administration. Cardiac disorders, hypertension, and recent injuries are all valid assessments but are likely to have been assessed during admission history taking and are not related to the purpose of administering the drug.
Answer to Question 2
B
Feedback:
Asthma is characterized by reversible bronchospasm, inflammation, and hyperactive airways. The hyperactivity is triggered by allergens or nonallergic inhaled irritants or by factors such as exercise and emotions. The trigger causes an immediate release of histamine, which results in bronchospasm in about 10 minutes. The later response (i.e., 3 to 5 hours) is cytokine-mediated inflammation, mucus production, and edema contributing to obstruction. Patients with asthma should not smoke at all and even minor respiratory infections should be treated to prevent an exacerbation of asthma and ADLs should be completed whenever the patient feels able.