Drugs Acting on the Lower Respiratory Tract

1.

A 70-year-old man is being treated for chronic obstructive pulmonary disease (COPD) with theophylline (Theo-Dur). What will be a priority assessment by the nurse?
A)
Ingestion of fatty foods
B)
Weight
C)
Activity level
D)
Use of nicotine
Ans:
D

Feedback:

Nutritional status, weight, and activity level would be important for a nurse to know about a COPD patient. However, it would be most important for the nurse to know whether the patient smokes or uses tobacco in other ways or smoking cessation methods that involve nicotine. Nicotine increases the metabolism of theophyllines; the dosage may need to be increased to produce a therapeutic effect.

2.

A 6-year-old child weighing 52 pounds has had a loading dose of aminophylline (Truphylline). The nurse is ready to administer the regular prescribed dose of 4 mg/kg every 4 hours for three doses. How many milligram will the patient receive in 12 hours?
A)
44 mg
B)
94 mg
C)
284 mg
D)
344 mg
Ans:
C

Feedback:

First, using the formula: 2.2 pounds and 52 pounds: times kg, determine the child’s weight in kg (52/2.2 = 23.64). Next, using the formula of amount of drug prescribed times weight in kg, determine the amount the child will receive in one dose (4 times 23.64 = 94.56). To determine the mg in a 12-hour period multiply 94.56 times 3 = 283.68. Round to 284 mg. Options A, B, and D are not correct.

3.

A patient is in the clinic to have blood drawn to assess his or her theophylline level. The patient is taking theophylline (Theo-Dur) and appears to being doing well on the drug. He or she reports no problems. What serum level will the nurse expect the patient to have?
A)
Between 0.5 to 5 mcg/mL
B)
Between 10 to 20 mcg/mL
C)
Between 25 to 35 mcg/mL
D)
Between 40 to 50 mcg/mL
Ans:
B

Feedback:

Therapeutic theophylline levels should be between 10 and 20 mcg/mL. A level between 0.5 and 5 mcg/mL would be low and would not produce a therapeutic effect. Levels between 25 and 50 mcg/mL would be too high and could cause serious adverse effects.

4.

A patient presents to the emergency department (ED) having an acute asthma attack. An ED physician has ordered a sympathomimetic (epinephrine). The nurse expects what as the therapeutic effect of this drug?
A)
Decrease the inflammatory response in the airways
B)
Reduce the surface tension within the alveoli allowing for gas exchange
C)
Inhibit the release of histamine and slow-reacting substance of anaphylaxis (SRSA) to prevent the allergic asthmatic response
D)
Cause dilation of the bronchi with increased rate and depth of respiration
Ans:
D

Feedback:

Epinephrine will cause the bronchi to dilate and also cause the rate and depth of respiration to increase. Inhaled steroids decrease the inflammatory response and lung surfactants reduce the surface tension within the alveoli. Mast cell stabilizers inhibit the release of histamine and SRSA to prevent the allergic response. Options A, B, and C are not correct.

5.

An inhaled sympathomimetic drug has been ordered for a teenage athlete who has exercise-induced asthma. What should the patient be instructed to do?
A)
Use the inhaler every day at the same time each day.
B)
Use the inhaler as soon as the symptoms start.
C)
Use the inhaler 30 to 60 minutes before exercising to ensure peak therapeutic levels when needed.
D)
Use the inhaler 2 to 3 hours before exercising to ensure peak effectiveness.
Ans:
C

Feedback:

Teaching a patient about using an inhaled sympathomimetic for management of exercise-induced asthma should include instructions to use the inhaler 30 to 60 minutes before exercising to ensure therapeutic levels when needed. The inhaler would not be used daily and waiting until symptoms occur will be too late for prevention. Options B and D are not correct.

6.

A premature newborn is being treated for respiratory distress syndrome. The nurse teaches the parents about what adverse effect that can occur with the use of lung surfactants?
A)
Kidney dysfunction
B)
Cardiac arrhythmias
C)
High fever
D)
Collapsed lung
Ans:
D

Feedback:

Lung surfactants used therapeutically can cause many adverse effects including pneumothorax (collapsed lung), hypotension, pulmonary leak, hyperbilirubinemia, and sepsis. Other adverse effects may occur in the infant related to the degree of immaturity of the child’s system and may not be related to the drug therapy. Options A, B, and C are not correct.

7.

A patient who has chronic bronchial asthma has had a mast cell stabilizer prescribed. What drug would the physician prescribe?
A)
Ipratropium or budesonide
B)
Isoetharine or montelukast
C)
Nedocromil or cromolyn
D)
Aminophylline or caffeine
Ans:
C

Feedback:

Nedocromil and cromolyn are mast cell stabilizers used in the treatment of asthma. Aminophylline and caffeine are xanthines. Ipratropium is an anti-cholinergic drug and budesonide is a corticosteroid. Isoetharine is a sympathomimetic drug and montelukast is a leukotriene receptor antagonist.

8.

A 76-year-old man with asthma is being treated with an anticholinergic. What will the nurse be careful to assess for?
A)
Cardiac arrhythmias
B)
Prostatic hypertrophy
C)
Thyroid conditions
D)
Parkinsonism
Ans:
B

Feedback:

Anticholinergics can produce urinary hesitancy and urinary retention, conditions that would aggravate the signs and symptoms of prostatic hypertrophy. Older patients given anti-cholinergics should be encouraged to empty the bladder before taking the drug. These drugs are used to treat parkinsonism. Thyroid conditions and cardiac arrhythmias are not cautions or contraindications to the use of these drugs.

9.

A patient with chronic bronchial asthma is prescribed montelukast (Singulair). What will the nurse instruct the patient to avoid taking?
A)
Aspirin
B)
Penicillin
C)
Sertraline (Zoloft)
D)
Nifedipine (Procardia)
Ans:
A

Feedback:

The nurse would instruct the patient to avoid aspirin, which might cause an increased montelukast level and toxicity. The other options do not cause drug–drug interactions with montelukast.

10.

A patient presents at the emergency department in acute respiratory distress. A quick assessment by the triage nurse indicates that the patient experienced difficulty breathing immediately after taking Combivent for the first time. The nurse suspects that the patient may be allergic to what?
A)
Aspirin
B)
Penicillin
C)
Peanuts
D)
Ragweed pollen
Ans:
C

Feedback:

Combivent is a combination drug of ipratropium and albuterol. The propellant used to make ipratropium has a cross-sensitivity to the antigen that causes peanut allergies. Aspirin, penicillin, and ragweed pollen are not associated with this drug.

11.

The nurse has admitted a patient (who takes ipratropium) to the respiratory unit with an acute exacerbation of chronic obstructive pulmonary disease (COPD). While writing a plan of care for this patient, what would be the most appropriate nursing diagnosis to use?
A)
Deficient knowledge regarding alternative therapy
B)
Imbalanced nutrition: Less than body requirements
C)
Acute pain related to renal effects of the drug
D)
Disturbed thought processes related to central nervous system (CNS) effects
Ans:
B

Feedback:

Nursing diagnoses related to drug therapy might include acute pain related to CNS, gastrointestinal (GI), or respiratory effects of the drug; imbalanced nutrition: Less than body requirements, related to dry mouth and GI upset; and deficient knowledge regarding drug therapy. Options A, C, and D are not correct.

12.

A patient, diagnosed with asthma, has been prescribed tiotropium (Spiriva). What should the nurse teach the patient about this drug? (Select all that apply.)
A)
It makes you fatigued.
B)
You need to stay out of direct sunlight.
C)
It is an anticholinergic.
D)
You only need to take it once a day.
E)
It has a rapid onset of action and a long duration.
Ans:
C, D, E

Feedback:

Tiotropium is the first drug approved for once-daily maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD). Patients who cannot tolerate the sympathetic effects of the sympathomimetics might respond to the anticholinergic drugs ipratropium (Atrovent) or tiotropium. Tiotropium has a rapid onset of action and a long duration, with a half-life of 5 to 6 days. Tiotropium is not associated with fatigue or photosensitivity.

13.

The nurse is providing health teaching to a newly diagnosed asthmatic patient. The patient has been prescribed theophylline. What is contraindicated with the use of this drug?
A)
Using insulin
B)
Taking anti-inflammatory drugs
C)
Exercising
D)
Smoking cigarettes
Ans:
D

Feedback:

Nicotine increases the metabolism of xanthines in the liver so that xanthine dosage must be increased in patients who continue to smoke while using xanthines. In addition, extreme caution must be used if the patient decides to decrease or discontinue smoking because severe xanthine toxicity can occur. Bronchoconstriction is not caused by using insulin and anti-inflammatory drugs do not cause bronchoconstriction. Exercise with a physician’s supervision is encouraged in individuals with asthma.

14.

What action by the patient would indicate that the patient understands how to use an inhaler?
A)
The patient inhales as soon as the inhaler enters his or her mouth.
B)
The patient holds his or her breath for several seconds after releasing the medication.
C)
The patient administers three doses of medication within a 1-minute time frame.
D)
The patient exhales as soon as he or she compresses the inhaler.
Ans:
B

Feedback:

Holding the breath prevents exhalation of medication still remaining in the mouth. The patient should inhale when the canister is compressed, not as soon as the inhaler enters his or her mouth. The patient should only administer one dose of medication at a time and the patient should wait to exhale until after the breath has been held as long as possible.

15.

A patient, newly diagnosed with chronic obstructive pulmonary disease (COPD), calls the clinic and asks the nurse to explain what the newly prescribed medications are for. What would be the most appropriate response by the nurse?
A)
“The medications that have been ordered for you are what the physician thinks will help you the most.”
B)
“The medications that have been ordered for you are to help you breathe easier.”
C)
“The medications that have been ordered for you are designed to work together to help you feel better.”
D)
“The medications that have been ordered for you are to help relieve the inflammation and promote dilation of the bronchi.”
Ans:
D

Feedback:

Drug treatment of asthma and COPD aims to relieve inflammation and promote bronchial dilation. The other options do not give the patient information about the use of these new medications.

16.

The nurse is caring for a patient who is taking an adrenergic bronchodilator. In what disease process should adrenergic bronchodilators be used cautiously?
A)
Liver failure
B)
Renal failure
C)
Respiratory failure
D)
Heart failure
Ans:
D

Feedback:

Adrenergic drugs cause cardiac stimulation. Patients with liver failure, renal failure, or respiratory failure do not need to use adrenergic bronchodilators cautiously.

17.

The patient is a 34-year-old man who recently started taking theophylline. The nurse knows that medication teaching has been successful when he agrees to what activity?
A)
Avoiding caffeine
B)
Eating foods high in potassium
C)
Limiting fluid intake to 1,000 mL a day
D)
Taking the medicine on an empty stomach
Ans:
A

Feedback:

Both theophylline and caffeine are xanthenes. Theophylline increases cardiac output and heart rate. Caffeine also stimulates heart rate. This can have an additive effect. Eating foods high in potassium, limiting fluid intake, or taking the medicine on an empty stomach are not indications that the patient has understood the nurse’s teaching.

18.

The nurse caring for a 38-year-old patient started on albuterol (Proventil) should advise the patient that he or she may experience what adverse effect?
A)
Polydipsia
B)
Tachycardia
C)
Hypotension
D)
Diarrhea
Ans:
B

Feedback:

Adrenergic agents stimulate beta1-adrenergic receptors in the heart as well as beta2-adrenergic receptors in the lungs. Adrenergic agents do not cause polydipsia, hypotension, or diarrhea.

19.

The nursing instructor is discussing bronchodilators with a group of nursing students. The students understand the instruction when they identify what drug is most effective in treating acute bronchospasm?
A)
Ipratropium bromide (Atrovent)
B)
Epinephrine (Adrenalin)
C)
Cromolyn (Intal)
D)
Ephedrine
Ans:
B

Feedback:

Epinephrine may be injected subcutaneously in an acute attack of bronchoconstriction, with therapeutic effects in 5 minutes that last 4 hours. It is considered the drug of choice for the treatment of acute bronchospasm. Ipratropium bromide has an onset of action of 15 minutes when inhaled with a duration of 3 to 4 hours. Cromolyn is not for use during acute times of bronchospasm but is used to help prevent bronchospasm. Ephedrine can be used in acute bronchospasm but epinephrine remains the drug of choice.

20.

A patient with chronic obstructive pulmonary disease (COPD) presents at the emergency department in acute respiratory distress. The patient’s family tells the nurse that the patient’s problems began right after the patient took his or her first dose of ipratropium (Atrovent). What would the nurse suspect is the problem?
A)
An allergy to milk
B)
Overexertion by the patient
C)
Patient not taking the medications correctly
D)
An allergy to soy products
Ans:
D

Feedback:

The use of ipratropium or tiotropium is contraindicated in the presence of known allergy to the drug or to soy products or peanuts (the vehicle used to make ipratropium an aerosol contains a protein associated with peanut allergies) to prevent hypersensitivity reactions. An allergy to milk is not associated with sensitivity to ipratropium. Overexertion would not cause the patient to develop respiratory distress after using ipratropium for the first time. Misuse of the inhaler would not cause respiratory distress.

21.

The nurse has provided health teaching for a 15-year-old boy newly diagnosed with asthma. What statement, made by the patient, indicates that he has a good understanding of the teaching the nurse has done regarding inhalers?
A)
“I should hold my breath when administering a puff.”
B)
“The aerosol canister should be shaken well before using.”
C)
“I need to take three short quick breaths when I administer the inhaler.”
D)
“A second aerosol medication cannot be administered until 30 minutes after the first aerosol medication.”
Ans:
B

Feedback:

Inhalers should be shaken well, immediately before each use. It would not be appropriate to teach the patient to hold his breath when administering a puff, to take three short quick puffs when administering the inhaler, or that a second aerosol medication should not be administered until 30 minutes after the first dose of aerosol medication.

22.

The nurse is writing a plan of care for a patient newly admitted to the floor with an asthma attack that occurred while exercising. What would be the most appropriate intervention for this patient?
A)
Assist patients with moderate to severe asthma in obtaining a home nebulizer unit
B)
Try to prevent or reduce panic, which may initiate bronchospasm
C)
Teach patient to use an inhaler before exercising
D)
Monitor peak flow rates, especially in children
Ans:
C

Feedback:

Teach patient who use one of these drugs for exercise-induced asthma to use it 30 to 60 minutes before exercising to ensure peak therapeutic effects when they are needed. The most important intervention would be to use a bronchodilator as prophylaxis for a patient with exercise-induced asthma. It would not be monitoring peak flow rates, trying to prevent or reduce panic, or assisting patient in obtaining a home nebulizer unit.

23.

A patient tells the nurse that a friend has recommended the use of caffeine to treat the patient’s asthma. The nurse counsels the patient to begin treatment immediately with the prescribed medication for what reason?
A)
Caffeine can aggravate the drugs used to treat asthma.
B)
Most natural products are less toxic or more potent than traditional asthma medications.
C)
Natural products decrease the adverse effects associated with adrenergic bronchodilators.
D)
Delays in appropriate treatment can have serious, even fatal, consequences.
Ans:
D

Feedback:

The xanthines, including caffeine and theophylline, come from a variety of naturally occurring sources. These drugs were formerly the main treatment choices for asthma and bronchospasm. However, because they have a relatively narrow margin of safety, and they interact with many other drugs, they are no longer considered the first-choice bronchodilators. Delays in appropriate treatment can have serious, even fatal, consequences. Natural products do not decrease the adverse effects associated with adrenergic bronchodilators. Natural products have not been proven to be less toxic or more potent than prescribed asthma medications. Caffeine does not aggravate drugs used to treat asthma, but it can have an additive effect.

24.

Epinephrine, formerly the drug of choice for acute attacks of bronchoconstriction, has been replaced by what?
A)
Short-acting bronchodilators are the drug of choice in this situation.
B)
Nothing has replaced epinephrine as drug of choice in this situation.
C)
Self-administered metered-dose inhalers (MDIs)
D)
Long-acting beta2-adrenergic agonists (LABAs)
Ans:
B

Feedback:

Epinephrine, the prototype drug, is the drug of choice in adults and children for the treatment of acute bronchospasm, including that caused by anaphylaxis; it is also available for inhalation therapy. Because epinephrine is associated with systemic sympathomimetic effects, it is not the drug of choice for patients with cardiac conditions. Options A, C, and D are not correct.

25.

A patient has an acute asthma attack. A bronchodilator is used to bring the exacerbation under control. What drug would be used to prevent acute bronchoconstriction?
A)
Salbutamol (Ventolin)
B)
Salmeterol (Serevent)
C)
Fenoterol (Berotec)
D)
Terbutaline (Bricanyl)
Ans:
B

Feedback:

Salmeterol (Serevent) and formoterol (Foradil) and are long-acting beta2-adrenergic agonists used only for prophylaxis of acute bronchoconstriction. Options A, C, and D are all short-acting beta2-adrenergic agonists and not used for prophylaxis.

26.

A patient is prescribed salmeterol with dosage on a 4 to 6 hour schedule for treatment of exercise-induced asthma. What is the recommended dosing schedule of asthma experts regarding this drug?
A)
30 minutes before exercise to prevent dyspnea during exercise
B)
Every 15 minutes during exercise to prevent dyspnea
C)
As needed to treat or prevent dyspnea during exercise
D)
Every 1 to 2 hours to treat or prevent dyspnea during exercise
Ans:
A

Feedback:

Salmeterol (Serevent) adult and pediatric (12-year-old and older): two puffs every 12 hours; or two puffs 30 to 60 minutes before exercise. Therefore, options B, C, and D are incorrect.

27.

The pharmacology instructor is explaining the difference between bronchodilators and anti-inflammatory drugs. How does an anti-inflammatory drug reduce bronchoconstriction?
A)
Increases ability to metabolize medication
B)
Decreases formation of mucus secretions
C)
Increases reactivity to medication
D)
By decreasing airway hyperreactivity to various stimuli
Ans:
D

Feedback:

Bronchodilators, or antiasthmatics, are medications used to facilitate respirations by dilating the airways. They are helpful in symptomatic relief or prevention of bronchial asthma and for bronchospasm associated with chronic obstructive pulmonary disease (COPD). Reducing inflammation prevents and reduces bronchoconstriction by decreasing airway hyperreactivity to various stimuli that decreases mucosal edema and formation of mucus secretions that narrow airways. Anti-inflammatory drugs do not increase the ability to metabolize medication or increases reactivity to medication.

28.

Why are inhaled steroids used to treat asthma and chronic obstructive pulmonary disease (COPD)?
A)
They act locally to decrease release of inflammatory mediators.
B)
They act locally to improve mobilization of edema.
C)
They act locally to increase histamine release.
D)
They act locally to decrease histamine release.
Ans:
A

Feedback:

When administered into the lungs by inhalation, steroids decrease the effectiveness of the inflammatory cells. This has two effects, which are decreased swelling associated with inflammation and promotion of beta-adrenergic receptor activity, which may promote smooth muscle relaxation and inhibit bronchoconstriction. Options B, C, and D are incorrect.

29.

The nurse is caring for a patient with chronic obstructive pulmonary disease. The plan of care will focus on what patient problem?
A)
Pain
B)
Obstructed airway
C)
Activity intolerance
D)
Adverse effects of medication therapy
Ans:
B

Feedback:

Asthma, emphysema, chronic obstructive pulmonary disease (COPD), and respiratory distress syndrome (RDS) are pulmonary obstructive diseases. All but RDS involve obstruction of the major airways. RDS obstructs the alveoli. Pain, activity intolerance, and adverse effects of medication therapy are conditions identified to detect, manage, and minimize the unexpected outcomes the nurse should be especially aware of the potential for an obstructed airway in these patients.

30.

The clinic nurse is caring for a patient who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The patient asks the nurse what COPD means. What would be the nurse’s best response?
A)
“It is an umbrella term for diseases like acute bronchitis.”
B)
“It means that the lungs have been damaged in such a way that there airflow is limited in and out of the lungs.”
C)
“It means your lungs can’t expand and contract like they are supposed to, which makes it hard for you to breathe.”
D)
“It is a term that covers so many lung diseases I can’t list them all.”
Ans:
B

Feedback:

The obstruction of asthma, emphysema, and COPD can be related to inflammation that results in narrowing of the interior of the airway and to muscular constriction that results in narrowing of the conducting tube. With chronic inflammation, muscular and cilial action is lost, and complications related to the loss of these protective processes can occur, such as infections, pneumonia, and movement of inhaled substances deep into the respiratory system. In severe COPD, air is trapped in the lower respiratory tract, the alveoli degenerate and fuse together, and the exchange of gases is greatly impaired. Options A, C, and D are not incorrect, but option B is the best response.

31.

The nurse is caring for a child who has been newly diagnosed with asthma. What environmental modifications should the nurse encourage the parents to make to help their child avoid future attacks? (Select all that apply.)
A)
Make sure the child begins herbal therapy as soon as possible.
B)
Avoid crowded areas as much as possible.
C)
Keep the child away from any known allergens.
D)
Encourage the child to use a broom to sweep the bedroom every day.
E)
Keep the child away from areas that are filled with cigarette smoke.
Ans:
B, C, E

Feedback:

Parents need to be encouraged to take measures to prevent acute attacks, including avoidance of known allergens, smoke-filled rooms, and crowded or dusty areas. OTC drugs and herbal remedies should be avoided if possible. The child should not be sweeping the bedroom because this will produce a lot of dust.

32.

The nursing instructor is talking to a group of nursing students about the treatment regimen for children with asthma. The students indicate they understand the information when they identify which class of drugs that comprise this regimen? (Select all that apply.)
A)
Long-acting inhaled steroids
B)
Xanthines
C)
Leukotriene-receptor antagonists
D)
Topical steroid nasal decongestants
E)
Beta-agonists
Ans:
A, C, E

Feedback:

Antiasthmatics are frequently used in children. The leukotriene-receptor antagonists have been found to be especially effective for long-term prophylaxis in children. Acute episodes are best treated with a beta-agonist and then a long-acting inhaled steroid or a mast cell stabilizer. Xanthines (e.g., theophylline) have been used in children, but because of their many adverse effects and the better control afforded by newer agents, its use is reserved for patients who do not respond to other therapies. Topical steroid nasal decongestants may be used for symptom relief for nasal congestion but are not a regular part of asthma therapy in children.

33.

The nurse has just admitted a patient with asthma and the emergency department doctor has ordered the patient to begin taking zafirlukast (Accolate). The nurse would hold the medication and contact the physician if the patient reported taking which medication at home? (Select all that apply.)
A)
Propranolol
B)
Warfarin
C)
Acetaminophen
D)
Ampicillin
E)
Terfenadine
Ans:
A, B, E

Feedback:

Use zafirlukast with caution if propranolol, theophylline, terfenadine, or warfarin is taken at the same time because increased toxicity can occur. Toxicity may also occur if these drugs are combined with calcium channel blockers, cyclosporine, or aspirin. No reported change of toxicity occurs when the patient is currently taking acetaminophen or ampicillin.

34.

A patient with asthma is going to begin taking an inhaled steroid. The nurse teaching the patient that what adverse effects may occur when using this drug? (Select all that apply.)
A)
Headache
B)
Rebound congestion
C)
Sepsis
D)
Epistaxis
E)
Depression
Ans:
A, B, D

Feedback:

Adverse effects associated with the use of inhaled steroids include irritability, not depression, headache, rebound congestion, local infection, not sepsis and epistaxis.

35.

The nursing instructor is discussing the use of sympathomimetics in patients who have acute bronchospasm. The instructor shares with the students that this classification of drugs is contraindicated or only used with great caution in patients with what disorders? (Select all that apply.)
A)
Hypothyroidism
B)
Cardiac disease
C)
Kidney disease
D)
Diabetes mellitus
E)
Peripheral vascular disease
Ans:
B, D, E

Feedback:

Before administering a sympathomimetic the nurse should assess for possible contraindications or cautions that include any known allergies to any drug in this class, cigarette use, cardiac disease, vascular disease, arrhythmias, diabetes, and hyperthyroidism. Sympathomimetics have no known adverse effects in hypothyroidism or kidney disease.