A nurse cares for a client who is infected with Burkholderia cepacia.
What action would the nurse take first when admitting this client to a pulmonary care unit?

Choice A rationale

Fine crackles are typically associated with fluid in the small airways or alveoli, as seen in conditions like pneumonia or heart failure, rather than the bronchoconstriction characteristic of asthma. During an acute asthma attack, the primary issue is narrowing of the bronchioles, leading to different adventitious sounds.

Choice B rationale

Coarse rhonchi are often indicative of secretions in larger airways, which can be cleared by coughing. While some mucus production can occur in asthma, coarse rhonchi are not the classic or primary auscultatory finding during an acute asthma attack, where airway smooth muscle constriction is the dominant pathology.

Choice C rationale

Expiratory wheezing is the hallmark auscultatory finding in an acute asthma attack. It is produced by the turbulent flow of air through narrowed lower airways, particularly during exhalation, as the bronchial smooth muscles constrict, and the airways become obstructed due to inflammation and mucus plugging.

Choice D rationale

Decreased breath sounds at the lung bases can indicate poor air entry into those areas, often due to atelectasis, pleural effusion, or severe airway obstruction. While severe asthma can lead to diminished breath sounds if airflow is severely compromised, expiratory wheezing is the more specific and classic initial finding during an acute exacerbation.

Choice A rationale

"What color is your sputum?" is a question related to the presence of infection or inflammation within the respiratory tract, providing insight into the nature of respiratory secretions. While important for overall respiratory assessment in COPD, it does not directly evaluate the client's functional capacity or activity tolerance.

Choice B rationale

"Do you have any difficulty sleeping?" directly assesses the impact of respiratory symptoms on rest and activity. Dyspnea, especially nocturnal or exertional dyspnea, can significantly impair sleep quality, indicating reduced activity tolerance and the inability of the respiratory system to meet oxygen demands during rest.

Choice C rationale

"How long does it take to perform your morning routine?" evaluates the client's ability to perform activities of daily living (ADLs). A prolonged duration or increased effort required for self-care tasks indicates diminished activity tolerance due to respiratory limitations, reflecting the physiological burden of COPD on daily functioning.

Choice D rationale

"Do you walk upstairs every day?" directly probes the client's capacity for common exertional activities. Walking upstairs is a standardized measure of functional exercise tolerance, and difficulty with this task signifies impaired respiratory reserve and reduced activity tolerance in individuals with chronic obstructive pulmonary disease.

Choice E rationale

"Have you lost any weight lately?" assesses nutritional status and systemic effects of chronic illness, often indicating the increased metabolic demands of breathing in COPD. While important for overall health, weight loss itself is not a direct measure of activity tolerance, but rather a consequence of severe disease progression.

Choice F rationale

"How does your activity compare to this time last year?" provides a valuable longitudinal perspective on the progression of COPD and the client's functional decline or stability. This comparison helps to quantify changes in activity tolerance over time, reflecting the effectiveness of treatment or disease progression.