Chapter 37: Respiratory Drugs

1. A patient has a metered-dose inhaler that contains 200 actuations ('puffs'), and it does not have a dose counter. He is to take two puffs two times a day. If he does not take any extra doses, identify how many days will this inhaler last at the prescribed dose. _______

ANS: 50 days Note the number of doses in the canister, and then calculate the number of days that the canister will last. For this question, assuming that two puffs are taken two times a day, and the inhaler has a capacity of 200 inhalations. Two puffs two times a day equal four inhalations per day. Four divided into 200 yields 50; that is, the inhaler will last approximately 50 days. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 594 TOP: NURSING PROCESS: Implementation

2. A patient will be receiving oral theophylline (Theo-Dur), 600 mg/day, in three divided doses. Identify how many milligrams will the patient receive per dose. _______

ANS: 200 mg DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation

5. After receiving a nebulizer treatment with a beta agonist, the patient complains of feeling slightly nervous and wonders if her asthma is getting worse. What is the nurse's best response? a. "This is an expected adverse effect. Let me take your pulse." b. "The next scheduled nebulizer treatment will be skipped." c. "I will notify the physician about this adverse effect." d. "We will hold the treatment for 24 hours."

ANS: A Nervousness, tremors, and cardiac stimulation are possible and expected adverse effects of beta agonists. The other options are incorrect responses. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 583 TOP: NURSING PROCESS: Assessment

6. A patient has prescriptions for two inhalers. One inhaler is a bronchodilator, and the other is a corticosteroid. Which instruction regarding these inhalers will the nurse give to the patient? a. "Take the corticosteroid inhaler first." b. "Take the bronchodilator inhaler first." c. "Take these two drugs at least 2 hours apart." d. "It does not matter which inhaler you use first."

ANS: B An inhaled bronchodilator is used before the inhaled corticosteroid to provide bronchodilation before administration of the anti-inflammatory drug. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 592 TOP: NURSING PROCESS: Implementation

2. A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for which adverse effects associated with the use of xanthine derivatives? a. Diarrhea b. Palpitations c. Bradycardia d. Drowsiness

ANS: B The common adverse effects of the xanthine derivatives include nausea, vomiting, and anorexia. In addition, gastroesophageal reflux has been observed to occur during sleep in patients taking these drugs. Cardiac adverse effects include sinus tachycardia, extrasystole, palpitations, and ventricular dysrhythmias. Transient increased urination and hyperglycemia are other possible adverse effects. DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 585 TOP: NURSING PROCESS: Evaluation

3. A patient is in an urgent care center with an acute asthma attack. The nurse expects that which medication will be used for initial treatment? a. An anticholinergic such as ipratropium (Atrovent) b. A short-acting beta2 agonist such as albuterol (Proventil) c. A long-acting beta2 agonist such as salmeterol (Serevent) d. A corticosteroid such as fluticasone (Flovent)

ANS: B The short-acting beta2 agonists are commonly used during the acute phase of an asthmatic attack to reduce airway constriction quickly and to restore airflow to normal levels. The other drugs listed are not appropriate for acute asthma attacks. Anticholinergic drugs and long-acting beta2 agonists are used to prevent attacks; corticosteroids are used to reduce airway inflammation. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 582 TOP: NURSING PROCESS: Planning

1. The nurse is reviewing medications for the treatment of asthma. Which drugs are used for acute asthma attacks? (Select all that apply.) a. Salmeterol (Serevent) inhaler b. Albuterol (Proventil) nebulizer solution c. Epinephrine d. Montelukast (Singulair) e. Fluticasone (Flovent) Rotadisk inhaler

ANS: B, C Albuterol (a short-acting beta2 agonist) and epinephrine (a beta1 and beta2 agonist) are used for acute bronchospasms. Salmeterol is a long-acting beta2 agonist that is indicated for maintenance treatment, not acute episodes. Fluticasone is an inhaled corticosteroid; montelukast is a leukotriene receptor antagonist (LTRA). These types of medications are used for asthma prophylaxis. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 591 TOP: NURSING PROCESS: Implementation

2. The nurse is providing instructions to a patient who has a new prescription for a corticosteroid metered-dose inhaler. Which statement by the patient indicates that further instruction is needed? (Select all that apply.) a. "I will rinse my mouth with water after using the inhaler and then spit out the water." b. "I will gargle after using the inhaler and then swallow." c. "I will clean the plastic inhaler casing weekly by removing the canister and then washing the casing in warm soapy water. I will then let it dry before reassembling." d. "I will use this inhaler for asthma attacks." e. "I will continue to use this inhaler, even if I am feeling better." f. "I will use a peak flow meter to measure my response to therapy."

ANS: B, D The inhaled corticosteroid is a maintenance drug used to prevent asthma attacks; it is not indicated for acute asthma attacks. Rinsing the mouth with water is appropriate and necessary to prevent oral fungal infections; the water is not to be swallowed after rinsing. The patient needs to be given instructions about keeping the inhaler clean, including removing the canister from the plastic casing weekly and washing the casing in warm soapy water. Once the casing is dry, the canister and mouthpiece may be put back together and the cap applied. The glucocorticoid may predispose the patient to oral fungal overgrowth, thus the need for implicit instructions about cleaning inhaling devices. Use of a peak flow meter assists in monitoring the patient's response to therapy. The medication needs to be taken as ordered every day, regardless of whether the patient is feeling better. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 594 TOP: NURSING PROCESS: Implementation

8. The nurse is monitoring drug levels for a patient who is receiving theophylline. The most recent theophylline level was 22 mcg/mL, and the nurse evaluates this level to be: a. below the therapeutic level. b. at a therapeutic level. c. above the therapeutic level. d. at a toxic level.

ANS: C Although the optimal level may vary from patient to patient, most standard references have suggested that the therapeutic range for theophylline blood level is 10 to 20 mcg/mL. However, most clinicians now advise levels between 5 and 15 mcg/mL. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 585 TOP: NURSING PROCESS: Evaluation

9. When evaluating a patient's use of a metered-dose inhaler (MDI), the nurse notes that the patient is unable to coordinate the activation of the inhaler with her breathing. What intervention is most appropriate at this time? a. Notify the doctor that the patient is unable to use the MDI. b. Obtain an order for a peak flow meter. c. Obtain an order for a spacer device. d. Ask the prescriber if the medication can be given orally.

ANS: C The use of a spacer may be indicated with metered-dose inhalers, especially if success with inhalation is limited. The other options are not appropriate interventions. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 591 TOP: NURSING PROCESS: Implementation

4. The prescriber has changed the patient's medication regimen to include the leukotriene receptor antagonist (LTRA) montelukast (Singulair) to treat asthma. The nurse will emphasize which point about this medication? a. The proper technique for inhalation must be followed. b. The patient needs to keep it close by at all times to treat acute asthma attacks. c. It needs to be taken every day on a continuous schedule, even if symptoms improve. d. When the asthma symptoms improve, the dosage schedule can be tapered and eventually discontinued.

ANS: C These drugs are indicated for chronic, not acute, asthma and are to be taken every day on a continuous schedule, even if symptoms improve. These drugs are taken orally. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 592 TOP: NURSING PROCESS: Implementation

7. When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects? a. Fatigue and depression b. Anxiety and palpitations c. Headache and rapid heart rate d. Oral candidiasis and dry mouth

ANS: D Oral candidiasis and dry mouth are two possible adverse effects of inhaled corticosteroids. The other responses are incorrect. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 592 TOP: NURSING PROCESS: Planning

10. The nurse is providing instructions about the Advair inhaler (fluticasone propionate and salmeterol). Which statement about this inhaler is accurate? a. It is indicated for the treatment of acute bronchospasms. b. It needs to be used with a spacer for best results. c. Patients need to avoid drinking water for 1 hour after taking this drug. d. It is used for the prevention of bronchospasms.

ANS: D Salmeterol is a long-acting beta2 agonist bronchodilator, while fluticasone is a corticosteroid. In combination, they are used for the maintenance treatment of asthma and COPD. As a long-acting inhaler, Advair is not appropriate for treatment of acute bronchospasms. The other statements are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 583 TOP: NURSING PROCESS: Implementation

1. A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. The nurse will assess for which therapeutic response? a. Increased sputum production b. Increased heart rate c. Increased respiratory rate d. Increased ease of breathing

ANS: D The therapeutic effects of bronchodilating drugs such as xanthine derivatives include increased ease of breathing. The other responses are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 593 TOP: NURSING PROCESS: Evaluation