Chapter 55: Drugs Acting on the Lower Respiratory Tract

A client is prescribed salmeterol as treatment for exercise-induced asthma. The nurse would instruct the client to use the inhaler at which time?

30 minutes before engaging in exercise Explanation: To prevent an exercise-induced asthma attack, the client should take one inhalation of salmeterol 30 minutes before starting exercise. The options would not be effective in preventing an attack.

A patient who is prescribed ipratropium administers the drug at 9:15 AM. The patient should begin to notice the drug beginning to act at which time?

9:30 AM Explanation: Inhaled ipratropium has an onset of action of 15 minutes, so the patient should begin to feel the effects of the drug at 9:30 AM.

After reviewing information about drugs used to treat lower respiratory system conditions, a group of nursing students demonstrate understanding of the information when they identify which as an example of a short-acting beta-2 agonist (SABA)?

Albuterol Explanation: Albuterol is a SABA. Formoterol, salmeterol, and arformoterol are all long-acting beta-2 agonists.

A client is experiencing an acute asthmatic attack. Which agent would be most effective?

Beta-2 selective adrenergic agonist Explanation: A beta-2 selective adrenergic agonist or sympathomimetic would be most appropriate because these agents are rapidly distributed after injection and rapidly absorbed after inhalation. An inhaled steroid would require 2 to 3 weeks to reach effective levels. Leukotriene receptor antagonists and mast cell stabilizers do not have immediate effects.

When describing the events of an asthma attack to a client, the nurse incorporates understanding that stimulation of alpha-adrenergic receptors results in which of the following?

Bronchoconstriction Explanation: Stimulation of alpha-adrenergic receptors results in bronchoconstriction. When leukotriene production is inhibited, bronchodilation is facilitated. Cough is a physiologic mechanism that causes the central airways to be cleared of foreign materials and excess secretions, and usually results from stimulation of sensory nerves in the airways. Inflammation of the mucosa is responsible for sputum production from increased mucus.

A nurse is providing health education to a client recently diagnosed with asthma and prescribed albuterol and ipratropium. Which of the client's statements suggests a need for clarification by the nurse?

I'll keep taking my medications until I'm not experiencing any more symptoms." Explanation: Antiasthma medications should normally be taken on a regular schedule, not solely based on immediate symptoms. They should not be discontinued in the absence of symptoms. Increasing fluid intake, limiting caffeine, and adhering to the administration schedule are correct actions.

Why are inhaled steroids used to treat asthma and COPD?

They act locally to decrease release of inflammatory mediators Explanation: 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, that may promote smooth muscle relaxation and inhibit bronchoconstriction.

The client has been prescribed cromolyn (Intal) for the treatment of asthma, and the nurse is evaluating the client's understanding of the medication. Which statement by the client indicates the need for further education?

"I will use this medication when I am having an asthma attack." Explanation: Cromolyn (Intal) is a mast cell stabilizer used in combination with other drugs in the treatment of asthma and other allergic disorders. Adverse reactions include drying of the throat and coughing or wheezing. It should not be used during an acute asthma attack because it may worsen the bronchospasm.

When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instructions are needed when the client makes which of the following statements?

"When I am short of breath, I will increase the use of my fluticasone." Explanation: Fluticasone is an inhaled steroid and should not be used during acute asthmatic attacks. Washing linens weekly will decrease the incidence of dust mites. When clients can participate in some, but not all of usual activities, they are in the yellow zone. Once medication is inhaled, the client should hold his or her breath for 10 seconds so that medication can reach deep into the lungs.

The nurse assesses the serum theophylline of a client. Which finding would the nurse identify as being therapeutic?

15 mcg/mL Explanation: Therapeutic theophylline levels range from 10 to 20 mcg/mL. A value of 15 mcg/mL would be considered therapeutic.

Mr. Ashum is prescribed an albuterol inhaler as part of his treatment regimen for asthma. What is the mechanism of action for this medication?

Albuterol causes relaxation of the bronchial smooth muscles. Explanation: The main result of albuterol binding to beta-2 receptors in the lungs is relaxation of bronchial smooth muscles. This relaxation of bronchial smooth muscle relieves bronchospasm, reduces airway resistance, facilitates mucous drainage, and increases vital capacity.

The nurse should complete which of the following during acute breathing distress before initiation of a bronchodilator? Select all that apply:

Check blood pressure. Check pulse. Check respiratory rate Explanation: Prior to initiation of a bronchodilator during acute breathing distress, the nurse needs to take a blood pressure, pulse, and respiratory rate.

The nurse is providing education to a client who has been prescribed an antiasthmatic drug. The nurse should instruct the client to avoid excessive intake of what beverage?

Coffee Explanation: Clients taking antiasthmatic drugs should generally avoid excessive intake of caffeine-containing fluids such as coffee, tea, and cola drinks. These beverages may increase bronchodilation but also may increase heart rate and cause palpitations, nervousness, and insomnia with bronchodilating drugs. None of the other options contain sufficient amounts of caffeine to cause such an affect.

Which of the following would be most important to assess before administering calfactant? (Select all that apply.)

Endotracheal tube placement Lung sounds Oxygen saturation levels Explanation: Before administering calfactant, it would be important to ensure proper endotracheal tube placement because the drug is instilled directly into the trachea. In addition, lung sounds and oxygen saturation levels would be important as a baseline to evaluate effectiveness of the drug.

A client is admitted to the emergency department with inspiratory stridor and air hunger. When anticipating treatment, the nurse will prepare which medication for administration?

Epinephrine Explanation: Epinephrine may be injected subcutaneously in an acute attack of bronchoconstriction. Ipratropium is administered by inhalation for maintenance therapy of bronchoconstriction related to chronic bronchitis and inflammation. It is not administered for an acute attack of bronchoconstriction. Cromolyn stabilizes mast cells and prevents the release of bronchoconstrictive and inflammatory substances when mast cells are confronted with allergens and other stimuli. It is not used for acute attacks. Pseudoephedrine is not administered for acute bronchoconstriction.

Isoproterenol is an anticholinergic agent.

False Explanation: Isoproterenol is a sympathomimetic agent.

Where should the nurse initially direct a client who is interested in learning more about the management of asthma?

Global Initiative for Asthma (GINA) Explanation: Management of asthma involves prevention of airway inflammation and avoidance of triggers for better symptom control. Because of asthma's significance as a world health problem, the Global Initiative for Asthma (GINA) published asthma guidelines of diagnosis, management, and education. These guidelines emphasize the importance of classifying asthma severity and the assessment of asthma control. While the other options may provide information on asthma, the GINA is most inclusive.

A client who smokes is receiving theophylline orally. Because of his history of smoking, the nurse expects the health care provider to do what with the theophylline dosing?

Increase Explanation: Nicotine from smoking interferes with the ability of the body to metabolize theophylline. Due to decreased metabolism, the dosage of theophylline would be increased.

The triage nurse in the emergency department has a 42-year-old client with asthma present for treatment. The client's respiratory rate is 40 breaths per minute. Based on this objective data, what is the correct nursing diagnosis for this client?

Ineffective breathing pattern Explanation: The correct nursing diagnosis is Ineffective Breathing Pattern related to impaired airway as manifested by tachypnea. The other options may be applicable, but they do not take priority over the ineffective breathing pattern.

A client is prescribed salmeterol. The nurse would expect this drug to be administered by which route?

Inhalation Explanation: Salmeterol is administered via inhalation.

The nurse is providing education to a client with asthma on the therapeutic action of inhaled corticosteroid agents. How will the nurse describe the action?

Inhaled corticosteroid agents reduce airway inflammation. Explanation: Inhaled corticosteroid agents suppress the release of inflammatory mediators, block the generations of cytokines, and decrease the recruitment of airway eosinophils. Inhaled corticosteroid agents do not depress the central nervous system or reduce bronchodilation or respiratory rate.

A neonate is receiving beractant. The nurse understands that this agent is administered by which route?

Intratracheal Explanation: Beractant is administered intratracheally.

A newborn, experiencing ineffective alveolar expansion, is receiving treatment. What intervention should the nurse implement to assure the administration of the prescribed medication has been effective?

Monitoring respirations for bilateral chest movement Explanation: Ensure proper placement of the endotracheal tube with bilateral chest movement and lung sounds to provide adequate delivery of the drug. Suctioning should be avoided for at least 2 hours after the surfactant is instilled into the newborn's endotracheal tube. Neither the delivery of supplemental oxygen nor position changes are related to the delivery of the medication into the infant's lungs

The client uses his sympathomimetic inhaler frequently. The nurse evaluates the client for which of the following symptoms related to frequent use of the sympathomimetic inhaler?

Nervousness Explanation: Frequent use of sympathomimetic inhalers can cause nervousness, hypertension, tachycardia, and anxiety.

A patient presents at the Emergency Department (ED) 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?

Peanuts Explanation: 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, or ragweed pollen are not associated with this drug.

A client with a diagnosis of asthma has been prescribed ipratropium 2 puffs QID. What is the most likely goal of this treatment?

Promoting long-term management of asthma symptoms Explanation: The anticholinergic bronchodilators are most useful in the long-term management of asthma and other conditions producing bronchoconstriction. These drugs are not used in the management of acute exacerbations of asthma. They do not promote alveolar blood flow.

The client with asthma has been ordered an inhaler and the nurse is teaching how to prevent Candida infections. Which would the nurse include in the instructions?

Rinse mouth with water after each use. Explanation: The client should be taught to rinse his mouth out with water after using oral inhalers to prevent a Candida oral infection. Candida is a yeast that can grow in the mouth, it is important that they have good oral hygiene but rinsing the mouth is sufficient. The client would not brush teeth between puffs, nor would they clean a spacer with alcohol. A spacer allows for better usage of the drug especially in children.

The nurse is evaluating the education of a client that uses albuterol for an acute asthma attack. The nurse knows that the lesson has been effective when the client states that albuterol is which of the following types of medication?

SABA Explanation: Albuterol is a short-acting beta-2 agonist (SABA). It is used to treat and prevent bronchospasm.

What pathology is present in a client diagnosed with chronic asthma even when they may appear symptom free? Select all that apply.

damaged airway mucosa airway inflammation Explanation: Inflammation and damaged airway mucosa are chronically present in asthma, even when clients appear symptom free. None of the other options are associated with chronic asthma.

A client has been prescribed medication therapy for the treatment of newly diagnosed asthma. During teaching, the nurse should alert the client to potential exacerbation of what concurrent medical condition?

gastroesophageal reflux disease Explanation: Asthma may aggravate gastroesophageal reflux disease because antiasthma medications that dilate the airways also relax muscle tone in the gastroesophageal sphincter and may increase acid reflux. The relationship between asthma medications and the other options is not supported by research data.

The nurse is providing education to the parents of a child who has been newly diagnosed with asthma. During teaching, the nurse should explain that asthma attacks occur when mast cells release substances that cause what reaction?

inflammation. Explanation: When lung tissues are exposed to causative stimuli, mast cells release substances that cause bronchoconstriction and inflammation, increased capillary permeability and fluid leakage, and changes in the mucus-secreting properties of the airway epithelium.

A client is receiving ipratropium as maintenance therapy for chronic obstructive pulmonary disease. The nurse would caution the client that up to how many inhalations may be used in 24 hours if needed?

12 Explanation: With ipratropium, the usual dosage is 2 inhalations four times/day for a total of 8 inhalations. However, the client can use up to 12 inhalations if needed in 1 day.

A male client presents to the emergency department in bronchospasm. He has a history of smoking two packs per day for 20 years and is prescribed phenytoin to control a seizure disorder that developed after a head injury 3 years ago. Based on the client's history, what would the nurse expect the health care provider to order?

A modified dose of aminophylline Explanation: Cigarette smoking and drugs that stimulate drug-metabolizing enzymes in the liver (e.g., phenobarbital, phenytoin) increase the rate of metabolism and, therefore, the dosage requirements of aminophylline.

A female client is prescribed systemic corticosteroids for her asthma. The nurse knows that the client is at risk for what problem?

Adrenal insufficiency Explanation: Adrenal insufficiency is most likely to occur with systemic or high doses of inhaled corticosteroids.

The nurse is performing a routine assessment of a client whose medical record indicates a history of asthma. What assessment findings would the nurse expect? Select all that apply.

Airway inflammation Damaged airway mucosa Explanation: Inflammation and damaged airway mucosa are chronically present in asthma, even when clients appear symptom free. Elevated temperature and bradycardia are unrelated to the client's asthma. Confusion can occur during an acute attack, but it would not be expected otherwise.

A client is prescribed a leukotriene receptor antagonist. The nurse should evaluate the effectiveness of the medication therapy based on the long term management of symptoms associated with which respiratory condition?

Asthma Explanation: Leukotriene receptor antagonists block or antagonize receptors for the production of leukotrienes D4 and E4, thus blocking many of the signs and symptoms of asthma. This class of medication is not typically associated with the long term management of any of the other options.

A client recently began taking theophylline for treatment of asthma. Which changes in the client's lifestyle would suggest that the client understands proper use of the drug and management of the disease?

Avoiding caffeine Explanation: Some bronchodilating drugs, such as theophylline, can cause tachycardia, arrhythmias, palpitations, agitation, and insomnia. Since caffeine, a mild bronchodilator, can add to these effects, clients should avoid excessive amounts while taking bronchodilating drugs. Clients with asthma and other bronchoconstrictive disorders should be encouraged to drink ample amounts of fluids each day to help thin secretions in the throat and lungs.

Which of the following would a nurse identify as a surfactant?

Beractant Explanation: Beractant is a lung surfactant. Cromolyn is a mast cell stabilizer. Zileuton is a leukotriene receptor antagonist. Theophylline is a xanthine.

A client is given theophylline to treat acute asthma symptoms. Which food should the client avoid?

Chocolate Explanation: Chocolate contains caffeine and is also a xanthine; thus chocolate should be avoided when the client is taking theophylline. Restriction of bananas, orange juice, and cranberry juice is not required.

A nurse is providing discharge planning for a 45-year-old woman who has a prescription for oral albuterol. The nurse will question the patient about her intake of which of the following?

Coffee Explanation: The nurse should assess the patient's intake of caffeine, including coffee, tea, soda, cocoa, candy, and chocolate. Caffeine has sympathomimetic effects that may increase the risk for adverse effects. Alcohol, salt, and vitamin C intake is important to assess, but does not potentiate the effects of albuterol.

A group of students are reviewing the various drugs that affect inflammation. The students demonstrate understanding when they identify which agent as a mast cell stabilizer?

Cromolyn Explanation: Cromolyn is a mast cell stabilizer. Montelukast is a leukotriene receptor antagonist. Calfactant is a lung surfactant. Triamcinolone is an inhaled steroid.

A patient tells you that a friend of theirs has recommended the use of caffeine to treat the patient's asthma. What would be the most important reason a nurse should counsel this patient not to delay prescribed treatment for the use of natural health products?

Delays in appropriate treatment can have serious, even fatal, consequences Explanation: The xanthines, including caffeine and theophylline, come from a variety of naturally occurring sources. These drugs were once 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.

A client with asthma is administered zileuton along with theophylline. The nurse should be especially alert for which of the following?

Increased serum theophylline Explanation: When administering zileuton along with theophylline, the nurse should monitor for increased serum theophylline. Serum zileuton levels and pulse rate are not increased when zileuton is administered along with theophylline. Increased prothrombin time is seen when warfarin, and not theophylline, is given along with zileuton.

The nurse is reviewing a client's morning blood work and notes a theophylline level of 22.2 mcg/mL (123.21 µmol/L). What action should the nurse take?

Inform the health care provider that the client has toxic theophylline levels. Explanation: To determine theophylline dosage, prescribers should measure serum theophylline levels. Therapeutic range is 5 to 15 mcg/mL (27.75 to 83.25 µmol/L); toxic levels are 20 mcg/mL (111 µmol/L) or above. The health care provider must be informed of this elevated serum level.

Mark, 8 years old, is prescribed flunisolide. The physician advises Mark and his parents to use a spacer when administering this medication. What is the benefit of such use?

It helps decrease systemic absorption. Explanation: Spacers help decrease systemic absorption, because less flunisolide is swallowed. Spacers may also help alleviate dysphonia by filtering larger aerosol particles that ordinarily deposit in the oropharynx and extrathoracic airways (this precaution also reduces the risk for oropharyngeal candidiasis). The use of a spacer does not prevent intrapulmonary delivery of the drug; nor does it reduce the risk of tachycardia and sinusitis.

An 8-year-old child with an acute asthmatic attack is receiving metaproterenol via nebulizer. Which of the following would be most appropriate?

Mix the drug with saline. Explanation: Metaproterenol is mixed with saline in the nebulizer chamber for administration. The child should sit upright or be in a semi-Fowler's position. He should breathe slowly and deeply during the treatment. The treatment is completed when all of the solution (liquid) is gone from the chamber.

A client, experiencing respiratory distress related bronchi constriction, will benefit from what therapeutic action provided by anticholinergic medication therapy?

Relaxation of smooth muscle Explanation: Anticholinergics can be used as bronchodilators because of their effect on the vagus nerve, resulting in relaxation of smooth muscle in the bronchi, which leads to bronchodilation. None of the other options describe the bronchial dilation affected of the anticholinergic classification of medications.

The nurse is providing care for a newborn who has received an instillation of surfactant. What assessment data indicates the infant is experiencing adequate oxygen perfusion? Select all that apply.

Skin is pink over entire body Skin warm to the touch Explanation: Assess the skin temperature and color to evaluate perfusion of a newborn receiving surfactant. Breath sounds and chest movement would be monitored to determine effective ventilation. Temperature would be monitored for possible infection.

The nurse is providing education to a client who has been prescribed albuterol. What adverse reaction should the nurse discuss during teaching?

Tachycardia Explanation: The symptoms of cardiac stimulation, including tachycardia, are noted with the administration of albuterol. The client will not experience polydipsia, hypotension, or diarrhea because of the effects of albuterol.

In children, high doses of nebulized albuterol have been associated with what conditions? (Select all that apply.)

Tachycardia Hypokalemia Hyperglycemia Explanation: In children, high doses of nebulized albuterol have been associated with tachycardia, hypokalemia, and hyperglycemia. Lowered or elevated blood pressure is not a usual issue with high doses of nebulized albuterol in children.

A nurse is providing education to a 56-year-old man who is admitted to the emergency department with an acute asthma attack. The nurse's initial assessment reveals that the patient has a history of pneumonia, drinks large quantities of coffee, and eats a high-calorie diet. Albuterol is prescribed for him. The important consideration when the nurse is preparing a teaching plan will be that the patient

has a high coffee intake. Explanation: Caffeine has sympathomimetic effects that may increase the risk for adverse effects with albuterol. The nurse should assess the patient's intake of caffeine through coffee, tea, soda, cocoa, candy, and chocolate. The patient's age, history of pneumonia, and preference for high-calorie food would not have important implications for his albuterol drug therapy.

A high school student was diagnosed with asthma when he was in elementary school and has become accustomed to carrying and using his "puffers". In recent months, he has become more involved in sports and has developed a habit of administering albuterol up to 10 times daily. The nurse should teach the student that overuse of albuterol can lead to

rebound bronchoconstriction. Explanation: Patients who self-administer albuterol may use their MDIs more frequently than recommended. This practice can result in rebound bronchoconstriction, which may motivate the patient to increase MDI use, stimulating the cycle of rebound congestion. Overuse of albuterol is not linked to pneumonia or hepatotoxicity. Albuterol is not an anticholinergic drug.