Chapter 39 Aerosol Drug Therapy (Test 1- Egans)

A physician wants to deliver a therapeutic aerosol to the upper airway (nose, larynx, trachea). To help ensure maximum deposition in this area, you would select an aerosol generator with an MMAD in what range? a. 5 to 50 m b. 2 to 5 m c. 1 to 3 m d. less than 1 m

ANS: A See Rule of Thumb p. 847.

Where do most aerosol particles that are less than 3 m deposit? a. alveoli b. bronchioles c. central airways d. upper airways

ANS: A See Rule of Thumb p. 847.s

Which of the following would be correct instructions for a patient being taught proper use of a dry power inhaler? 1. Place mouthpiece 4 cm from mouth. 2. Exhale slowly to FRC. 3. Inhale slowly (less than 30 L/min). 4. Repeat until dose is used up. a. 2 and 4 b. 3 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

ANS: A See Box 36-4. DIF: Recall REF: p. 859 OBJ: 5

For which of the following patient groups is use of a dry power inhaler (DPI) for bronchodilator administration NOT recommended? 1. infants and children younger than 5 years 2. patients with an acute bronchospastic episode 3. patients requiring maintenance therapy a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: A Because infants, small children (younger than 5 years) (Figure 36-17), and those not able to follow instructions cannot develop flow this high, these patient groups cannot use DPIs. Patients with severe airway obstruction also may not be able to achieve the required flow; therefore, DPIs should not be used in the management of acute bronchospasm. DIF: Recall REF: p. 859 OBJ: 5

Which of the following would you recommend to optimize drug delivery with a small-volume jet nebulizer (SVN) to an intubated, mechanically ventilated patient? 1. Increase dose to compensate for decreased delivery. 2. Place SVN in the inspiratory line 18 inches from the patient "wye." 3. Disconnect or bypass heated humidifier system. 4. Turn off flow-by or continuous flow while nebulizing. 5. Adjust ventilator volume or pressure limit for added flow. a. 1, 2, 3, and 5 b. 2, 3, and 4 c. 1, 2, and 3 d. 1, 2, 3, 4, and 5

ANS: A Box 36-9 outlines the optimal technique for drug delivery by SVN to intubated patients undergoing mechanical ventilation. DIF: Application REF: p. 878 OBJ: 5

84. Which of the following aerosol drug delivery devices would you recommend against using with a toddler or small child? 1. metered-dose inhaler (MDI) 2. small-volume jet nebulizer 3. dry powder inhaler 4. MDI, holding chamber, and mask a. 1 and 2 b. 1 and 3 c. 2 and 4 d. 3 and 4

ANS: A See Rule of Thumb p. 871. DIF: Application REF: p. 871 OBJ: 9

Which of the following devices would you select to deliver an aerosolized bronchodilator to a young child? a. metered-dose inhaler (MDI) and spacer b. MDI, holding chamber, and mask c. MDI and holding chamber d. dry power inhaler

ANS: B Holding chambers with masks are available for use in the care of infants, children, and adults. DIF: Recall REF: p. 856 OBJ: 5

What is the most reliable indicator of a change in airway resistance due to bronchodilator administration during mechanical ventilation? a. change in slope of the expiratory flow-volume curve b. difference between peak airway and plateau pressures c. change in peak expiratory flow during passive exhalation d. difference between plateau and baseline (PEEP) pressures

ANS: B A change in the differences between peak and plateau pressures (the most reliable indicator of a change in airway resistance during continuous mechanical ventilation) can be measured. DIF: Recall REF: p. 878 OBJ: 8

What is the major problem with using large-volume nebulizers for continuous aerosol drug therapy? a. decreased pulmonary deposition b. drug reconcentration and toxicity c. frequent interruption of therapy d. greater waste of drug

ANS: B A potential problem with continuous bronchodilator therapy is drug concentration increase. DIF: Recall REF: p. 866 OBJ: 5

The key difference between a metered-dose inhaler (MDI) holding chamber and a spacer is that the holding chamber incorporates which of the following? a. larger enclosed space b. one-way inspiratory valve c. heated chamber d. series of baffles

ANS: B A spacer is a simple valveless extension device that adds distance between the pMDI outlet and the patient's mouth. See Box 36-2. DIF: Recall REF: p. 855 OBJ: 5

Which of the following is the effect of aerosol particles entrained into a warm and fully saturated gas stream? a. no effect b. increase in size c. decrease in size d. increase in number

ANS: B Aerosol particles entrained into a warm and fully saturated gas stream increase in size. DIF: Recall REF: p. 861 OBJ: 5

As hygroscopic aerosol particles enter the respiratory tract, what do they tend to do? a. decrease in size because of the absorption of molecular water b. increase in size because of the absorption of molecular water c. increase in size because of the evaporation of molecular water d. decrease in size because of the evaporation of molecular water

ANS: B Aerosols of water-soluble materials, especially salts, tend to be hygroscopic, absorbing water and growing when introduced into a high-humidity environment. DIF: Recall REF: p. 847 OBJ: 2

Most of the spray generated by the majority of metered-dose inhalers consists of which of the following? a. active drug b. propellant c. surfactant agents d. water solution

ANS: B Approximately 60% to 80% by weight of this spray consists of the propellant. DIF: Recall REF: p. 851 OBJ: 5

After actuating a metered-dose inhaler with a holding chamber, what should the patient be instructed to do? a. Take a large breath and hold it for at least 5 seconds. b. Continue to breathe through the device for three breaths. c. Immediately exhale as fast and as much as possible. d. Take one quick breath and remove the holding chamber.

ANS: B DIF: Recall REF: p. 854 OBJ: 5

You increase the fill volume from 2 to 4 ml in a small-volume jet nebulizer being used to administer a bronchodilator agent with an aerosol. What effect will this have on the amount of drug delivered? a. no effect b. increase c. decrease d. more waste

ANS: B Increasing the fill volume allows a greater proportion of active medication to be nebulized. DIF: Application REF: p. 861 OBJ: 6

93. Which of the following is false about the use of the peak expiratory flow rate (PEFR) in assessing a patient's response to bronchodilator therapy? a. PEFR and lab spirometry forced vital capacity values may correlate poorly. b. PEFR is the standard for determining bronchodilator response. c. Some peak flowmeters are more accurate and reliable than others. d. The peak flow measure is effort and volume dependent.

ANS: B Although peak flow measurement can be used at the bedside to assess treatment effectiveness and to monitor trends, conventional spirometry remains the standard for determining bronchodilator response. DIF: Recall REF: p. 874 OBJ: 8

78. Which of the following are true about a solution that is being aerosolized by an ultrasonic nebulizer? 1. The solute concentration decreases. 2. The temperature of the solution increases. 3. The solute concentration increases. 4. The temperature of the solution decreases. a. 1 and 2 b. 2 and 3 c. 2 and 4 d. 3 and 4

ANS: B As the temperature increases, the drug concentration increases, as does the likelihood of undesired side effects. DIF: Recall REF: p. 867 OBJ: 5

85. On the average, what percentage of an aerosol drug delivery device's output actually deposits in the lungs? a. less than 10% b. 10% c. 20% d. 30%

ANS: B Depending on device and patient, as little as 10% or less of drug emitted from an aerosol device may be deposited in the lungs (Figure 36-31). DIF: Recall REF: p. 874 OBJ: 5

106. What is the best way to confirm that an asthmatic outpatient can properly self-manage a newly prescribed aerosol drug therapy? a. Have the patient describe the proper procedural steps. b. Have the patient provide a repeat or return demonstration. c. Have the patient take a written or oral quiz on technique. d. Have the patient maintain detailed treatment logs.

ANS: B Patients should be able to demonstrate good technique regarding the use of each aerosol device that they are expected to use in self-care. Practitioner demonstration followed by repeated patient return demonstration is a must, and should be reviewed frequently, such as with each office/clinic visit. DIF: Recall REF: p. 875 OBJ: 7

87. Possible complications associated with the selection of an aerosol drug delivery device include all of the following except: a. underdosing or overdosing because of improper technique b. overhydration or fluid imbalances c. adverse effects of the specific drug agent d. environmental contamination or caregiver exposure

ANS: B See Box 36-7. DIF: Recall REF: p. 873 OBJ: 5

Which of the following techniques will increase aerosol deposition by sedimentation in the lungs? a. high inspiratory flow b. short inspiratory time c. 10-second breath-hold d. short expiratory time

ANS: C A 10-second breath-hold can increase aerosol deposition as much as 10% and increase the ratio of aerosol deposited in lung parenchyma to central airway by fourfold.

The mass of aerosol particles produced by a nebulizer in a given unit time best describes which quality of the aerosol? a. stability b. density c. output d. deposition

ANS: C Aerosol output is defined as the mass of fluid or drug contained in aerosol produced by a nebulizer generated per unit of time.

A patient with an acute exacerbation of asthma is not responding to the standard dose and frequency of an aerosolized bronchodilator and is now receiving small-volume jet nebulizer (SVN) therapy every 30 minutes. Which of the following would you recommend to the patient's physician at this time? a. Discontinue the aerosolized bronchodilator. b. Increase the frequency of SVN therapy to every 10 minutes. c. Consider continuous nebulization of the drug. d. Add more diluent to the SVN to extend treatment time.

ANS: C An alternative approach is to provide continuous nebulization with a specialized large-volume nebulizer. DIF: Application REF: p. 865 OBJ: 6

Where do most aerosol particles in the 1- to 5-m range deposit? a. alveoli b. bronchioles c. central airways d. upper airways

ANS: C Sedimentation occurs mostly in the central airways and increases with time, affecting particles down to 1 m in diameter.

When using a chamber-style adapter with a metered-dose inhaler (MDI) to deliver a bronchodilator to a patient receiving mechanical ventilation, with what would you coordinate MDI firing? a. beginning of inspiration b. beginning of exhalation c. end of inspiration d. middle of inspiration

ANS: A Box 36-9 outlines the optimal technique for drug delivery by pressurized MDI to intubated patients undergoing mechanical ventilation. DIF: Recall REF: p. 878 OBJ: 5

For which of the following patients would you recommend against using a flow-triggered metered-dose inhaler (MDI) as the sole bronchodilator delivery system? a. patient likely to develop acute severe bronchospasm b. stable elderly patient on maintenance bronchodilator therapy c. teenage asthmatic who refuses to use a holding chamber d. patient who cannot coordinate MDI firing with inhalation

ANS: A Caution may be appropriate in ordering breath-triggered pMDIs for small children and patients prone to severe levels of airway obstruction. DIF: Analysis REF: p. 850 OBJ: 5

With which of the following devices are therapeutic aerosols generated? 1. atomizers 2. nebulizers 3. humidifiers a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: A In the clinical setting, medical aerosols are generated with atomizers, nebulizers, or inhalers.

Proper use of a dry power inhaler (DPI) requires that the patient be able to do which of the following? a. generate inspiratory flows of 60 L/min or higher b. exhale forcibly through the device before drug delivery c. inhale slowly (less than 0.5 L/sec) and perform a breath-hold d. coordinate firing of the DPI with inspiration

ANS: A Individual doses are inhaled as soon as the seal is broken. The high peak inspiratory flow rates (greater than 60 L/min) required to dispense the drug powder from most current DPI designs result in a pharyngeal dose comparable with that received from a typical pressurized metered-dose inhaler without an add-on device. DIF: Recall REF: p. 858 OBJ: 5

What is the primary mechanism for deposition of large, high-mass particles (greater than 5 m) in the respiratory tract? a. inertial impaction b. sedimentation c. diffusion d. Brownian motion

ANS: A Inertial impaction occurs when suspended particles in motion collide with and are deposited on a surface. This is the primary deposition mechanism for particles larger than 5 m.

When using a small-particle aerosol generator (SPAG) to administer ribavirin (Virazole) to an infant, which pair of flow settings is correct? Nebulizer Drying Chamber a. b. c. d.

ANS: A Nebulizer flow should be maintained at approximately 7 L/min with total flow from both flowmeters no lower than 15 L/min. DIF: Recall REF: p. 866 OBJ: 5

What is the primary fate of inhaled aerosol particles that are between 1 and 0.5 m? a. Most are cleared during exhalation. b. Most deposit in the central airways. c. Most deposit in the upper airway. d. Most deposit in the alveoli.

ANS: A Particles between 1 and 0.5 m are so stable that most remain in suspension and are cleared with the exhaled gas.

Which of the following aerosols would have the highest rate of deposition by diffusion? a. MMAD of 0.1 m b. MMAD of 3.0 m c. MMAD of 10.0 m d. MMAD of 50.0 m

ANS: A Particles smaller than 0.5 m have a greater retention rate in the lungs.

Which of the following particle distributions is produced by a typical metered-dose inhaler? a. 2 to 6-m mean mass aerodynamic diameter (MMAD) b. 1- to 3-m MMAD c. 6- to 9-m MMAD d. less than 1-m MMAD

ANS: A Pressurized metered-dose inhalers can produce particles in the respirable range (MMAD 2 to 6 m). DIF: Recall REF: p. 853 OBJ: 5

All of the following device-related factors have a major effect on pressurized metered-dose inhaler (MDI) delivery of aerosolized drugs during mechanical ventilation except: a. MDI propellant formula b. type of spacer or adapter used c. position of spacer in circuit d. timing of MDI actuation

ANS: A See Table 36-5. DIF: Recall REF: p. 878 OBJ: 5

109. A physician orders continuous bronchodilator therapy with 1:200 albuterol for an asthmatic patient at the dosage of 20 mg/hr. How much 1:200 albuterol will be needed for the first hour of treatment? a. 2 ml b. 3 ml c. 4 ml d. 5 ml

ANS: C See Mini Clini p.877. DIF: Recall REF: p. 877 OBJ: 5

Which of the following are beneficial effects of using a holding chamber with a metered-dose inhaler (MDI)? 1. reduction in oropharyngeal aerosol deposition 2. decrease in need for hand-breath coordination 3. elimination of medication waste a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: A Spacers and valved holding chambers are pressurized MDI accessory devices designed to reduce both oropharyngeal deposition and/or the need for hand-breath coordination. DIF: Recall REF: p. 854 OBJ: 5

To minimize a patient's infection risk between drug treatments with a small-volume jet nebulizer (SVN), what would you do? a. Rinse the SVN with sterile water; air dry. b. Carefully repackage the SVN in its wet state. c. Rinse the SVN with tap water; run until dry. d. Throw out the SVN after every treatment.

ANS: A The Centers for Disease Control and Prevention recommends that nebulizers be cleaned and disinfected, or rinsed with sterile water, and air-dried between uses. DIF: Application REF: p. 865 OBJ: 6

Which of the following will increase aerosol deposition by inertial impaction? 1. high-velocity gas flow 2. variable or irregular passages 3. turbulent gas flow 4. particles of high mass a. 2 and 3 b. 2, 3, and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

ANS: A The greater the mass and velocity of a moving object, the greater is its inertia and the greater is the tendency of that object to continue moving along its set path (Figure 36-1).

Indications of an adverse drug response during continuous bronchodilator therapy include all of the following except: a. decreased consciousness b. worsening tachycardia c. vomiting d. palpitations

ANS: A The patient must be observed for adverse drug responses, including worsening tachycardia, palpitations, and vomiting. DIF: Recall REF: p. 877 OBJ: 8

What is the primary hazard of aerosol drug therapy? a. untoward drug reactions b. pulmonary infection c. airway reactivity d. drug reconcentration

ANS: A The primary hazard of aerosol drug therapy is an adverse reaction to the medication being administered. DIF: Recall REF: p. 847 OBJ: 4

This problem of ribavirin (Virazole) aerosol precipitation causing malfunction of ventilator circuits can be overcome by which of the following? 1. Placing a one-way valve between the small-particle aerosol generator (SPAG) and the circuit 2. Placing a HEPA filter proximal to the exhalation valve 3. Decreasing the SPAG's total flow to below 10 L/min a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: A This problem can be overcome by (1) placing a one-way valve between the SPAG and the circuit and (2) filtering out the excess aerosol particles before they reach the exhalation valve, changing filters frequently to avoid increasing expiratory resistance. DIF: Recall REF: p. 866 OBJ: 5

On the average, what is the range of the actual pulmonary deposition of small-volume jet nebulizer aerosolized drugs in intubated patients receiving mechanical ventilation? a. 1.5% to 3.0% b. 3.5% to 6.0% c. 6.5% to 9.0% d. 9.5% to 15.0%

ANS: A Under normal conditions with heated humidification and standard jet nebulizers, pulmonary deposition ranges between 1.5% and 3.0%. DIF: Recall REF: p. 878 OBJ: 1

Which of the following agents has been associated with increased intraocular pressure? a. anticholinergics b. epinephrine c. 2-agonists d. antibiotics

ANS: A Use of anticholinergic agents has been associated with increased ocular pressure, which could be dangerous for patients with glaucoma. DIF: Recall REF: p. 854 OBJ: 5

90. Which of the following would you recommend as initial therapy for a patient admitted to the emergency department with acute airway obstruction (wheezing, cough, dyspnea, peak expiratory flow rate [PEFR] less than 60% predicted)? 1. Assess dose-response of metered-dose inhaler (MDI) albuterol (up to 12 puffs). 2. Provide up to three small-volume jet nebulizer (SVN) treatments with albuterol every 20 minutes. 3. Immediately begin continuous albuterol therapy at 15 mg/hr. a. 1 or 2 b. 1 or 3 c. 2 or 3 d. 1, 2, and 3

ANS: A According to the algorithm, a patient with acute airway obstruction (wheezing, cough, dyspnea, and PEFR less than 60% of predicted value) would receive up to three SVN treatments with a standard dose of albuterol, repeated at 20-minute intervals, or 4 puffs of pressurized MDI albuterol with a holding chamber (up to 12 puffs). DIF: Recall REF: p. 873-874 OBJ: 8

95. When assessing a patient's response to bronchodilator therapy, you notice a decrease in wheezing accompanied by an overall decrease in the intensity of breath sounds. Which of the following is most likely? a. increasing airway obstruction b. improving ventilation/perfusion ratio ( ) c. decreasing airway obstruction d. deteriorating oxygenation

ANS: A In terms of breath sounds, a decrease in wheezing accompanied by an overall decrease in the intensity of breath sounds indicates worsening airway obstruction or patient fatigue. DIF: Application REF: p. 874 OBJ: 8

100. An asthmatic patient in severe distress with wheezing and dyspnea is admitted to the emergency department. After a conducting a full assessment and obtaining a pretreatment baseline, you start the patient on albuterol with a small-volume jet nebulizer. You should continue assessing and documenting all appropriate variables before and after each treatment until what point? a. The patient's symptoms are relieved, or the peak expiratory flow rate (PEFR)/forced expiratory volume in 1 second (FEVl) exceeds 70% of "personal best." b. The patient's wheezing disappears, and the intensity of breath sounds decreases. c. The patient's symptoms are relieved, or the PEFR/FEVl returns to the predicted normal. d. The patient's SpO2 is above 90%, and the PEFR/FEVl returns to the predicted normal.

ANS: A See Box 36-8. DIF: Application REF: p. 875 OBJ: 8

98. In a dose-response assessment of a patient's response to a metered-dose inhaler bronchodilator, when would you stop increasing the dose? 1. when the peak expiratory flow rate improves <10% to 15% 2. when tachycardia occurs 3. when tremors are evident 4. when 6 to 8 puffs are delivered a. 1, 2, and 3 b. 1, 3, and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: A See Box 36-8. DIF: Recall REF: p. 875 OBJ: 8

What is the primary mechanism for central airway deposition of particles in the 1- to 5-m range? a. impaction b. sedimentation c. diffusion d. Brownian motion

ANS: B During normal breathing, sedimentation is the primary mechanism for deposition of particles in the 1- to 5-m range.

Which of the following describes the mass of drug leaving the mouthpiece of a nebulizer as aerosol? a. single dose b. emitted dose c. multiple dose d. output dose

ANS: B For drug delivery systems, emitted dose describes the mass of drug leaving the mouthpiece of a nebulizer or inhaler as aerosol.

All of the following drugs or drug categories have been associated with increased airway resistance and bronchospasm during aerosol administration except: a. steroids b. albuterol c. acetylcysteine d. antibiotics

ANS: B Medications such as acetylcysteine, antibiotics, steroids, cromolyn sodium, ribavirin, and distilled water have been associated with increased airway resistance and wheezing during aerosol therapy. DIF: Recall REF: p. 849 OBJ: 4

A physician wants to deliver a therapeutic aerosol to the central and lower airways. To help ensure maximum deposition in this area, you would select an aerosol generator with an MMAD in what range? a. 5 to 20 m b. 2 to 5 m c. 1 to 3 m d. less than 1 m

ANS: B See Rule of Thumb p. 847. DIF: Application REF: p. 847 OBJ: 2

All of the following ventilator-related factors have a major effect on metered-dose inhaler delivery of aerosolized drugs during mechanical ventilation except: a. mode of support b. presence of positive end-expiratory pressure c. VT d. duty cycle

ANS: B See Table 36-5. DIF: Recall REF: p. 878 OBJ: 5

What serious problems associated with the delivery of ribavirin (Virazole) using the small-particle aerosol generator (SPAG)? 1. caregiver exposure to the drug aerosol 2. drug reconcentration in the drying chamber 3. drug precipitation in ventilator circuits a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: B Serious problems associated with the delivery of ribavirin (Virazole) using the small-particle aerosol generator (SPAG) include caregiver exposure to the drug aerosol and drug precipitation when delivered through a mechanical ventilation circuit. The first is caregiver exposure to the drug aerosol. Approaches to limit caregiver exposure are discussed later (see Controlling Environmental Contamination). The other problem occurs only when the SPAG is used to deliver ribavirin through a mechanical ventilator circuit. Drug precipitation can jam breathing valves or occlude the ventilator circuit. DIF: Recall REF: p. 866 OBJ: 5

A physician has ordered the antiviral agent ribavirin (Virazole) to be administered by aerosol to an infant with bronchiolitis. Which of the following devices would you recommend in this situation? a. hydrodynamic (Babbington) nebulizer b. small-particle aerosol generator (SPAG) c. ultrasonic (piezoelectric) nebulizer d. large-volume heated jet nebulizer

ANS: B The SPAG was manufactured by ICN Pharmaceuticals specifically for the administration of ribavirin (Virazole) to infants with respiratory syncytial virus infection. DIF: Recall REF: p. 866 OBJ: 5

The small-particle aerosol generator (SPAG) produces a small monodisperse aerosol through which of the following? a. aerosol impaction by sequential baffling b. particle evaporation in a glass drying chamber c. use of an inert liquefied gas propellant d. aerosol generation using vibrational energy

ANS: B The device is unique in clinical respiratory care practice in that it incorporates a drying chamber with its own flow control to produce a stable aerosol. DIF: Recall REF: p. 866 OBJ: 5

Which of the following drugs present the greatest exposure risks for health care workers? 1. albuterol (Proventil) 2. pentamidine (Pentam 300) 3. ribavirin (Virazole) 4. acetylcysteine (Mucomyst) a. 1 and 4 b. 2 and 3 c. 1, 2, and 3 ]d. 2, 3, and 4

ANS: B The greatest occupational risk for respiratory therapists has been associated with administration of ribavirin and pentamidine. DIF: Recall REF: p. 882 OBJ: 10

Each firing of a typical metered-dose inhaler delivers about what output volume? a. 10 to 30 l b. 30 to 100 l c. 10 to 30 ml d. 30 to 100 ml

ANS: B The output volume of pressurized metered-dose inhalers varies from 30 to 100 l. DIF: Recall REF: p. 851 OBJ: 5

Which of the following is false about changes in aerosol suspensions over time? a. Liquid aerosol particles can shrink (evaporation) or grow (water absorption). b. The rate of particle growth is directly proportional to particle size. c. Small water-based particles tend to shrink when exposed to dry gas. d. Aerosols of water-soluble salts tend to grow in a humidified environment.

ANS: B The relative rate of particle size change is inversely proportional to the size of a particle, so the small particles grow or shrink faster than larger particles. DIF: Recall REF: p. 847 OBJ: 2

What is the average amount of dead volume in a small-volume jet nebulizer after the device runs dry? a. 0.1 ml b. 0.5 to 2.2 ml c. 2.0 to 4.0 ml d. less than 0.1 ml

ANS: B The residual volume of a 3-ml dose varies from as little as 0.5 ml to more than 2.2 ml, which can be more than two thirds of the total dose. DIF: Recall REF: p. 860 OBJ: 5

97. Which of the following best describes a proper a dose-response assessment of a metered-dose inhaler (MDI) bronchodilator? a. Give 4 puffs one after the other, wait 1 minute, repeat up to 16 puffs. The best dose is the highest dose given without side effects. b. Give 4 puffs spaced 1 to 2 minutes apart; repeat up to 12 puffs with continued improvement. The best dose provides maximum subjective relief and the highest peak expiratory flow rate (PEFR) without side effects. c. Give 12 puffs 1 minute apart; repeat every 20 minutes until maximum relief of symptoms is achieved without side effects. d. Give 2 puffs 1 to 2 minutes apart; repeat up to 6 puffs with continued improvement. The best dose provides maximum subjective relief and the highest PEFR without side effects.

ANS: B A simple albuterol dose-response titration involves giving an initial 4 puffs (90 g/puff) at 1-minute intervals through an pressurized MDI with a holding chamber. If after 5 minutes, airway obstruction is not relieved, the respiratory therapist gives 1 puff per minute until symptoms are relieved, heart rate increases to more than 20 beats/min, tremors increase, or 12 puffs are delivered. The best dose is that which provides maximum relief of symptoms and the highest PEFR without side effects. DIF: Recall REF: p. 874 OBJ: 8

101. After initially conducting a pre- and post-bronchodilator assessment on a stable asthmatic patient admitted to the hospital, how often would you recommend reassessment of peak expiratory flow rate/forced expiratory volume in 1 second? a. with each treatment b. twice daily c. once per day d. every other day

ANS: B See Box 36-8. DIF: Recall REF: p. 875 OBJ: 8

81. What is the average mean mass aerodynamic diameter (MMAD) generated by the vibrating mesh nebulizers? a. 1 to 2 m b. 2 to 3 m c. 3 to 4 m d. 5 to 6 m

ANS: B The exit velocity of the aerosol is low, less than 4 m/sec, and the particle size can range between 2 to 3 m MMAD, varying with the exit diameter of the apertures (Figure 36-27). DIF: Recall REF: p. 869 OBJ: 5

A patient on mechanical ventilation was given 4 puffs of albuterol 5 minutes ago through a metered-dose inhaler (MDI) and holding chamber placed 18 inches from the circuit's airway connector. The patient continues to exhibit clinical signs of increased airway resistance but has demonstrated no apparent side effects from the drug. Which of the following would you recommend at this time? a. Discontinue the albuterol and switch to a systemic bronchodilator. b. Repeat administration until the desired response is achieved. c. Remove the circuit-holding chamber and repeat MDI actuation. d. Move the MDI closer to the patient's airway and repeat use.

ANS: B; Box 36-9 outlines the optimal technique for drug delivery by pressurized MDI to intubated patients undergoing mechanical ventilation. DIF: Application REF: p. 878 OBJ: 6

What measure is used to identify the particle diameter, which corresponds to the most typical settling behavior of an aerosol? a. mean mass velocity coefficient (MMVC) b. logarithmic standard diameter (LSD) c. mean mass aerodynamic diameter (MMAD) d. geometric standard deviation (GSD)

ANS: C Because medical aerosols contain particles of many different sizes (are heterodisperse), the average particle size is expressed with a measure of central tendency, such as MMAD for cascade impaction or volume median diameter (VMD) for laser diffraction.

What term describes the primary mechanism for deposition of small particles? a. hygroscopic condensation b. gravity sedimentation c. Brownian diffusion d. inertial impaction

ANS: C Brownian diffusion is the primary mechanism for deposition of small particles (less than 3 m), mainly in the respiratory region where bulk gas flow ceases and most aerosol particles reach the alveoli by diffusion.

Exhalation into which device can result in loss of drug delivery? a. small-volume jet nebulizers b. metered-dose inhaler c. dry power inhaler d. ultrasonic nebulizer

ANS: C Exhalation into the dry powder inhaler before inspiration can result in loss of drug delivery to the lung. DIF: Recall REF: p. 859 OBJ: 5

A patient with chronic bronchitis is receiving heated water aerosol treatments through a jet nebulizer four times daily to aid in mobilizing retained secretions. After each treatment, you note a dramatic increase in the magnitude of coarse crackles heard on auscultation. Which of the following recommendations would you make to the physician? a. Discontinue the heated water aerosol treatments. b. Switch to a higher-density aerosol (e.g., ultrasonic). c. Add coughing and postural drainage to the therapy. d. Consider prior treatment with a bronchodilator.

ANS: C For patients unable to clear their own secretions, suctioning or other airway clearance techniques may be indicated as an adjunct to aerosol therapy. DIF: Application REF: p. 849 OBJ: 4

Most nebulizers used in respiratory care produce which type of aerosol suspension? a. monodisperse b. microaerosol c. heterodisperse d. macroaerosol

ANS: C Most aerosols found in nature and used in respiratory care are composed of particles of different sizes, described as heterodisperse.

Which of the following devices depends on the patient's inspiratory effort to dispense the dose? a. small-volume jet nebulizers b. metered-dose inhaler c. dry power inhaler d. ultrasonic nebulizer

ANS: C Passive or patient-driven, dry power inhalers rely on the patient's inspiratory effort to dispense the dose. DIF: Recall REF: p. 858 OBJ: 5

What is a potential limitation of flow-triggered metered-dose inhaler devices? a. increased pharyngeal impaction b. less effective lung deposition c. high flows necessary for actuation d. requires accessory equipment

ANS: C Patients experiencing an acute exacerbation of bronchospasm may not be able to generate sufficient flows to trigger the Autohaler. DIF: Recall REF: p. 850 OBJ: 5

What is the preferred method for delivering bronchodilators to spontaneously breathing and intubated, ventilated patients? a. dry powder inhaler b. small-volume jet nebulizer c. metered-dose inhaler d. hand-bulb atomizer

ANS: C Pressurized metered-dose inhalers often are the preferred method for delivering bronchodilators to spontaneously breathing patients as well as those who are intubated and undergoing mechanical ventilation. DIF: Recall REF: p. 851 OBJ: 5

Before inspiration and actuation of a metered-dose inhaler, the patient should exhale to which of the following? a. total lung capacity b. residual volume c. functional residual capacity d. expiratory reserve volume

ANS: C See Box 36-1. DIF: Recall REF: p. 853 OBJ: 5

When using a metered-dose inhaler without a holding chamber or a spacer, the patient should be instructed to fire the device at what point? a. immediately before beginning a slow inspiration b. immediately after beginning a slow exhalation c. immediately after beginning a slow inspiration d. immediately before beginning a slow exhalation

ANS: C See Box 36-1. DIF: Recall REF: p. 853 OBJ: 5

To ensure delivery of the proper drug dosage with a metered-dose inhaler, which of the following must be done before its use? 1. The canister valve stem should be cleaned with a pin. 2. The canister should be warmed to hand or body temperature. 3. The canister should be vigorously shaken. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: C See Box 36-3. DIF: Recall REF: p. 856 OBJ: 5

To decrease the VDS of a small-volume jet nebulizer during drug administration, what should you do? a. Decrease the nebulizer flow. b. Turn the nebulizer upside-down. c. continue treatment until nebulizer begins to sputter d. Increase the nebulizer flow.

ANS: C See Box 36-6. DIF: Application REF: p. 861-866 OBJ: 6

Normally, when using a 50-psi flowmeter to drive a small-volume jet nebulizer, to what should you set the flow? a. 2 to 4 L/min b. 4 to 6 L/min c. 6 to 10 L/min d. 8 to 10 L/min

ANS: C See Box 36-6. DIF: Recall REF: p. 866 OBJ: 5

During aerosol drug delivery using a small-volume jet nebulizer (SVN) set at 8 L/min input flow, a patient asks that the head of the bed be lowered to a semi-Fowler's position. Immediately after doing so, you observe a significant drop in SVN aerosol output, despite there being at least 3 ml of solution left in the reservoir. What would you do to correct this problem? a. Add 1 to 2 ml more diluent to the nebulizer reservoir. b. Increase the nebulizer input flow to 10 to 12 L/min. c. Reposition the patient so that the SVN is more upright. d. Decrease the nebulizer input flow to 3 to 4 L/min.

ANS: C Some SVNs stop producing aerosol when tilted as little as 30 degrees from vertical. DIF: Analysis REF: p. 861 OBJ: 6

To decrease the likelihood of an opportunistic yeast or fungal infection associated with metered-dose inhaler (MDI) steroids, what would you recommend that a patient do? 1. Cut in half the number of puffs or treatments. 2. Use a spacer or holding chamber. 3. Rinse the mouth after each treatment. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: C The high percentage of oropharyngeal drug deposition with use of steroid pressurized MDIs (pMDIs) can increase the incidence of opportunistic oral yeast infection (thrush) and changes in the voice (dysphonia). Rinsing the mouth after steroid use can help avoid this problem, but most pMDI steroid aerosol impaction occurs deep in the hypopharynx, which cannot be easily rinsed with gargling. For this reason, steroid pMDIs should not be used alone but always in combination with a spacer or valved holding chamber. DIF: Application REF: p. 854 OBJ: 5

What is the process by which aerosol suspension changes over time? a. evaporation b. deposition c. aging d. sublimation

ANS: C The process by which an aerosol suspension changes over time is called aging. DIF: Recall REF: p. 847 OBJ: 2

In mouth-breathing adult patients, which of the following factors is crucial in determining whether to use a mask or mouthpiece for aerosol drug delivery with a small-volume jet nebulizer? a. clinician experience b. drug concentration c. patient preference and comfort d. brand of small-volume jet nebulizer

ANS: C The selection of delivery method (mask or mouthpiece) should be based on patient ability, preference, and comfort. DIF: Recall REF: p. 862 OBJ: 5

Which of the following is a common method to measure aerosol particle size? a. scan b. gravimetric c. cascade impaction d. penetration studies

ANS: C The two most common laboratory methods used to measure aerosol particle size are cascade impaction and laser diffraction.

To provide an extra margin of safety during continuous bronchodilator therapy (CBT), which of the following would you recommend be monitored? 1. eosinophil count 2. serum potassium levels 3. Electrocardiogram a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: C To provide an extra margin of safety, some clinicians recommend that patients receiving CBT undergo continuous electrocardiographic monitoring and measurement of serum potassium level every 4 hours. DIF: Recall REF: p. 877 OBJ: 8

Which of the following is false about the optimal technique for using a small-volume jet nebulizer (SVN) for aerosol drug delivery? a. SVNs are less technique- and device-dependent. b. Slow inspiration improves SVN aerosol deposition. c. Deep breathing or breath-holding improves SVN deposition. d. Use of a mouthpiece or mask provides similar results.

ANS: C Use of an SVN is less technique and device dependent than use of a pressurized metered-dose inhaler or dry powder inhaler delivery system. Slow inspiratory flow does optimize SVN aerosol deposition. However, deep breathing and breath-holding during SVN therapy do little to enhance deposition over normal tidal breathing. Because the nose is an efficient filter of particles larger than 5 mm, many clinicians prefer not to use a mask for SVN therapy. As long as the patient is mouth-breathing, there is little difference in clinical response between therapy given by mouthpiece and that given by mask. DIF: Recall REF: p. 862 OBJ: 7

108. What is the recommended dosage for continuous bronchodilator therapy (CBT)? a. 0.5 mg/hr b. 5.0 mg/hr c. 15.0 mg/hr d. 50.0 mg/hr

ANS: C According to this protocol, children older than 6 years with tachypnea and those with hypoxemia, increased work of breathing, and restlessness who do not respond to standard therapy are given CBT with a large-volume nebulizer or small-volume jet nebulizer at a dosage of 15 mg/hr. DIF: Recall REF: p. 876 OBJ: 5

103. For a hospitalized patient who will require ongoing maintenance bronchodilator therapy after discharge, what should your end goal be? a. complete relief of all patient symptoms b. normal airflow and cessation of therapy c. effective self-administration of the drug d. peak expiratory flow rate that exceeds 70% of "personal best"

ANS: C For patients who need ongoing maintenance therapy after the acute phase of illness, the goal should be effective self-administration. DIF: Recall REF: p. 875 OBJ: 8

107. After administering 12 puffs of metered-dose inhaler (MDI) albuterol to an acutely ill asthmatic patient in the emergency department, assessment indicates no significant improvement in symptoms. Which of the following would you now recommend? a. Switch over to high-dose MDI steroids. b. Discontinue the bronchodilator therapy. c. Use continuous bronchodilator therapy. d. Switch over to an anticholinergic agent.

ANS: C If these strategies fail to provide relief, continuous bronchodilator therapy (CBT) with nebulized albuterol doses ranging from 5-20 mg/hour have proved safe and effective for both adult and pediatric patients. DIF: Application REF: p. 875 OBJ: 8

96. When assessing a patient's response to bronchodilator therapy, you notice a decrease in wheezing accompanied by an overall increase in the intensity of breath sounds. Which of the following is most likely? a. increasing airway obstruction b. improving c. decreasing airway obstruction d. deteriorating oxygenation

ANS: C Improvement is indicated when wheezing decreases and the overall intensity of breath sounds increases. DIF: Application REF: p. 874 OBJ: 8

82. In selecting the appropriate aerosol drug delivery device for a given patient, what must you consider? 1. available drug formulation(s) 2. desired site of deposition 3. patient's characteristics 4. patient's preference a. 1 and 2 b. 1 and 3 c. 2 and 4 d. 1, 2, 3, and 4

ANS: C In selecting the appropriate aerosol delivery device for a given patient, the following must be considered: (1) the available drug formulation, (2) the desired site of deposition, (3) the patient's characteristics (age, acuity of respiratory problem, alertness, and ability to follow instructions), (4) ability to properly use the device, and (5) the patient's preference. DIF: Recall REF: p. 870 OBJ: 5

88. A semiconscious patient with inadequate spontaneous ventilation requires aerosol drug administration. Which of the following approaches would you recommend? a. large-volume continuous nebulizer b. small-volume jet nebulizer (SVN) c. SVN with delivery by intermittent positive-pressure breathing d. metered-dose inhaler and holding chamber

ANS: C See Box 36-7. DIF: Application REF: p. 873 OBJ: 5

102. What schedule of peak expiratory flow rate assessment would you recommend for a home care asthmatic patient? a. 1 to 2 times daily (on rising and at bedtime) b. once per day (on rising or at bedtime) c. 3 to 4 times daily (on rising, noon, 4 to 7 PM, bedtime) d. 1 to 2 times daily (at noon and around bedtime)

ANS: C See Box 36-8. DIF: Application REF: p. 875 OBJ: 8

Drug aerosol delivery systems include all of the following except: a. dry powder inhalers (DPIs) b. small-volume jet nebulizers c. metered-dose inhalers (MDIs) d. spinning disk nebulizers

ANS: D Aerosol generators in use include pressurized metered-dose inhalers (pMDIs) with or without spacers/holding chambers, dry powder inhalers (DPIs), small and large volume (jet) nebulizers, ultrasonic nebulizers (USNs), hand-bulb atomizers (including nasal spray pumps), vibrating mesh nebulizers, and a number of emerging technologies. DIF: Recall REF: p. 849 OBJ: 5

Which of the following best defines an aerosol? a. suspension of liquid droplets in a gas b. suspension of particulate matter in a gas c. molecular water dispersed throughout a carrier gas d. suspension of liquid or solid particles in a gas

ANS: D An aerosol is a suspension of solid or liquid particles in gas.

About what range of drug dosages can be provided with each firing of a metered-dose inhaler? a. 5 to 50 mg b. 50 to 100 mg c. 5 to 50 g d. 50 g to 5 mg

ANS: D Approximately 60% to 80% by weight of this spray consists of the propellant, with only approximately 1% being active drug (50 g to 5 mg, depending on the drug formulation). DIF: Recall REF: p. 851 OBJ: 5

Side effects of environmental exposure to ribavirin or pentamidine aerosols include all of the following except: a. bronchospasm b. skin rashes c. conjunctivitis d. tachyphylaxis

ANS: D Conjunctivitis, headaches, bronchospasm, shortness of breath, and rashes have been reported among those administering these drugs. DIF: Recall REF: p. 882 OBJ: 10

Advantages of the dry power inhaler (DPI) drug delivery systems include all of the following except: a. low relative cost b. no propellants required c. no hand-breath coordination necessary d. unaffected by humidity

ANS: D DPIs are relatively inexpensive, do not need propellants, and do not require the handbreath coordination needed for pressurized metered-dose inhalers. DIF: Recall REF: p. 857 OBJ: 5

To minimize the risk of infection associated with aerosol drug therapy, what should you do? 1. Sterilize nebulizers between patients. 2. Frequently replace in-use units. 3. Rinse nebulizers with sterile water. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Guidelines from the Centers for Disease Control and Prevention state that nebulizers should be sterilized between patients, frequently replaced with disinfected or sterile units, or rinsed with sterile water (not tap water), and air-dried every 24 hours. DIF: Recall REF: p. 849 OBJ: 4

To monitor a patient for the possibility of reactive bronchospasm during aerosol drug therapy, what should you do? 1. Measure pre- and post-peak flow and/or percentage forced expiratory volume in 1 second (%FEV1). 2. Auscultate for adventitious breath sounds. 3. Carefully observe the patient's response. 4. Communicate with the patient during therapy. a. 1 and 3 b. 1, 3, and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: D Monitoring for reactive bronchospasm should include peak flow measurements or percentage forced expiratory volume in 1 second (%FEV1) before and after therapy; auscultation for adventitious breath sounds, and observation of the patient's breathing pattern and overall appearance; and, most essential, communication with the patient during therapy to determine the perceived work of breathing (WOB). DIF: Application REF: p. 849 OBJ: 4

Where do most aerosol particles in the 5- to 10-m range deposit? a. alveoli b. bronchioles c. central airways d. upper airways

ANS: D Particles in the 5- to 10-m range tend to become deposited in the oropharynx and hypopharynx, especially with the turbulence created by the transition of air as it passes around the tongue and into the larynx.

Which of the following methods can be used to minimize the harmful effects of environmental exposure to ribavirin or pentamidine aerosols? 1. Use an isolation booth or tent with HEPA filtered exhaust. 2. Have health care personnel wear a HEPA filtered mask. 3. Use a negative pressure room with adequate air exchange. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Patients given aerosolized ribavirin or pentamidine must be treated in a private room, booth, or tent or at a special station designed to minimize environmental contamination. DIF: Recall REF: p. 882 OBJ: 10

Immediately after firing, the aerosol particles produced by most metered-dose inhalers are about how large? a. 1 m b. 5 m c. 20 m d. 35 m

ANS: D Propellant evaporation causes the initially large particles (35 m) generated at the actuator orifice to rapidly decrease in size. DIF: Recall REF: p. 851 OBJ: 5

All of the following drug formulation characteristics affect the performance of small-volume jet nebulizers except: a. homogeneity b. surface tension c. viscosity d. potency

ANS: D See Box 36-5. DIF: Recall REF: p. 860 OBJ: 5

All of the following source gas characteristics affect the performance of small-volume jet nebulizers except: a. humidity b. flow c. pressure d. viscosity

ANS: D See Box 36-5. DIF: Recall REF: p. 860 OBJ: 5

Which of the following small-volume jet nebulizer design features affect its performance? 1. position 2. residual volume 3. baffles 4. reservoirs a. 1, 2, and 3 b. 2 and 4 c. 3 and 4 d. 1, 2, 3, and 4

ANS: D See Box 36-5. DIF: Recall REF: p. 860 OBJ: 5

A physician wants to deliver a therapeutic aerosol to the lung parenchyma (alveolar region). To help ensure maximum deposition in this area, you would select an aerosol generator with an MMAD in what range? a. 5 to 20 m b. 2 to 5 m c. 1 to 3 m d. less than 1 m

ANS: D See Rule of Thumb p. 847. DIF: Application REF: p. 847 OBJ: 2

All of the following circuit-related factors have a major effect on metered-dose inhaler delivery of aerosolized drugs during mechanical ventilation except: a. endotracheal tube size b. type of humidifier c. relative humidity d. temperature

ANS: D See Table 36-5. DIF: Recall REF: p. 878 OBJ: 5

Which of the following groups of patients are most likely to have difficulty using a simple metered-dose inhaler for aerosol drug therapy? 1. patients in acute distress 2. infants and young children 3. elderly persons a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Some patients, especially infants, young children, the elderly, and patients in acute distress, may not be able to coordinate actuation of the pressurized metered-dose inhaler with inspiration. DIF: Recall REF: p. 850 OBJ: 5

What measure is used to describe the variability of particle diameters in an aerosol? a. MMVC b. LSD c. MMAD d. GSD

ANS: D The GSD describes the variability of particle sizes in an aerosol distribution set at 1 standard deviation (SD) above or below the median (15.8% and 84.13%).

When fired inside the mouth, what percentage of the drug dose delivered by a simple metered-dose inhaler (MDI) deposits in the oropharynx? a. about 20% b. about 40% c. about 60% d. about 80%

ANS: D The initial velocity and dispersion of the aerosol plume generate larger particles that decrease in size as they leave the pressurized MDI, resulting in approximately 80% of the dose leaving the actuator to impact and become deposited in the oropharynx. DIF: Recall REF: p. 853 OBJ: 5

What is the retention of aerosol particles resulting from contact with the respiratory tract mucosa called? a. stability b. density c. penetration d. deposition

ANS: D When aerosol particles leave suspension in gas they deposit on (attach to) a surface.

Which of the following factors affect pulmonary deposition of an aerosol? 1. size of the particles 2. shape and motion of the particles 3. physical characteristics of the airways a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Whether aerosol particles that are inhaled into the lung are deposited in the respiratory tract depends on the size, shape, and motion of the particles and on the physical characteristics of the airways and breathing pattern.

What happens as the pressure or flow delivered through a small-volume jet nebulizer gets higher? 1. Treatment time becomes shorter. 2. Particle size becomes smaller. 3. Aerosol output becomes greater. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Within operating limits, the higher the pressure or flow, the smaller is the particle size, the greater is the output, and the shorter is the treatment time. DIF: Recall REF: p. 861 OBJ: 5

104. Which of the following factors is most crucial in developing an effective program of aerosol drug self-administration in an adult patient requiring maintenance bronchodilator therapy? a. proper device selection b. well-written brochures c. reliable peak expiratory flow rate meter d. good patient education

ANS: D An effective program of aerosol drug self-administration depends on thorough patient education. DIF: Recall REF: p. 875 OBJ: 8

80. Advantages of small-volume ultrasonic nebulizers for drug delivery include all of the following except: a. greater respirable drug mass b. less dead space and waste c. increased mobility d. decreased cost

ANS: D Both theoretical advantages of the ultrasonic devices are outweighed by relatively high purchase costs and poor reliability. DIF: Recall REF: p. 867 OBJ: 5

83. For maintenance administration of bronchodilators to an adult patient with adequate inspiratory flow, which of the following aerosol drug delivery devices would you recommend? 1. pressurized metered-dose inhaler (pMDI) 2. small-volume jet nebulizer 3. dry powder inhaler 4. pMDI and holding chamber a. 1 or 2 b. 2 or 3 c. 2 or 4 d. 3 or 4

ANS: D For administration of maintenance therapy bronchodilators and antiinflammatory agents to adults, a pMDI with a valved holding chamber is the most convenient, versatile, and cost-effective approach. Dry powder inhalers are gaining popularity as an equivalent to pMDIs for maintenance therapy with available drugs for patients capable of generating adequate inspiratory flow. DIF: Application REF: p. 856-858 OBJ: 5

94. In addition to bedside pulmonary function test measures, what other components of patient assessment are useful in evaluating bronchodilator therapy? 1. patient interview and observation 2. measurement of vital signs 3. chest auscultation 4. arterial blood gas analysis and oximetry a. 1, 3, and 4 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: D Other components of patient assessment useful in evaluating bronchodilator therapy include patient interviewing and observation, measurement of vital signs, auscultation, blood gas analysis, and oximetry. DIF: Recall REF: p. 874 OBJ: 8

86. Factors associated with reduced pulmonary deposition of aerosolized drugs include all of the following except: a. mechanical ventilation b. artificial airways c. poor patient technique d. mouth breathing

ANS: D See Box 36-7. DIF: Recall REF: p. 873 OBJ: 5

99. An asthmatic patient in severe distress with wheezing and dyspnea is admitted to the emergency department and started on albuterol via small-volume jet nebulizer. Which of the following approaches would you recommend to assess this therapy for this patient? 1. Perform arterial blood gas analysis. 2. Continuously monitor the SpO2. 3. Assess breath sounds and vital signs before and after each treatment. 4. Measure peak expiratory flow rate or forced expiratory volume in 1 second before and after each treatment. a. 1 and 2 b. 1, 3, and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: D See Box 36-8. DIF: Application REF: p. 875 OBJ: 8

89. To assess the effectiveness of a particular aerosol delivery device selection, what would you evaluate? 1. patient's technique in using the device 2. patient's response to and compliance with procedure 3. objective measures of improvement (e.g., peak flow) a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: D See Box 36-8. DIF: Recall REF: p. 875 OBJ: 8

91. Indications for assessment of patient's response to bronchodilator therapy include all of the following except to: a. confirm whether the therapy works as intended b. individualize the dose, frequency, or type of medication c. help follow the patient's status during long-term therapy d. quantify the degree of bronchial hyperresponsiveness

ANS: D The AARC has published Clinical Practice Guideline: Assessing Response to Bronchodilator Therapy at Point of Care. See Box 36-8. DIF: Recall REF: p. 875 OBJ: 8

92. Appropriate documentation when conducting point-of-care assessment of a patient's response to bronchodilator therapy includes all of the following except: a. medication type, dose, and time received b. vital signs, breath sounds, and pulmonary function test measures c. patient's progress and ability to self-assess symptoms d. blood levels of the bronchodilator agent

ANS: D The AARC has published Clinical Practice Guideline: Assessing Response to Bronchodilator Therapy at Point of Care. See Box 36-8. DIF: Recall REF: p. 875 OBJ: 8

79. Which of the following make small-volume ultrasonic drug delivery systems different from their large-volume counterparts? 1. They do not use a couplant compartment. 2. Drugs are placed directly on the transducer. 3. Battery power is available on some units. 4. Patient flow, not a blower, carries the aerosol. a. 2 and 4 b. 3 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

ANS: D Unlike the larger units, some of these systems do not use a couplant compartment; the medication is placed directly into the manifold on top of the transducer. The transducer is connected by cable to a power source, often battery-powered to increase portability. These devices have no blower; the patient's inspiratory flow draws the aerosol from the nebulizer into the lung. DIF: Recall REF: p. 867 OBJ: 5

105. Which of the following patient skills are necessary to ensure effectiveness of drug administration via the aerosol route? 1. ability to keep track of dosing requirements 2. understanding of the methods and goals of therapy 3. ability to recognize undesirable side effects a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Whenever possible, patients should be taught to understand the basic administration techniques, to keep track of dosing requirements, to recognize undesirable side effects, and to understand the options and actions required to reduce or eliminate these effects. DIF: Recall REF: p. 875 OBJ: 7